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#91 of 105 Old 05-16-2012, 09:15 AM
 
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In regards to how doctors are paid and financial incentives to surgery - it should get a great big fat "It Depends."
 

Some doctors are on salary.  I delivered both my kids at teaching hospitals, using OBs and MWs who worked in clinics at those hospitals.  The doctors were on salary and were scheduled for a certain number of days per week seeing patients in clinic, and a certain number of shifts on L&D.  Same for MWs.  When you came in to deliver, whoever was on shift delivered your baby.  This is a pretty good system, because it removes many incentives for the doctor to manipulate the method and timing of delivery - how and when you deliver affected neither their pay nor their hours (although the OB and the nursing team did stay over the end of their shifts to see me through when DS was born).  Their c-section rates were still higher on weekdays, because scheduled c-sections and inductions all took place then.

 

The Boston Globe (sadly paywalled) did an article about c-section rates in MA hospitals last year, in which they discussed hospital staffing models and their relationship to c-section rates.  The staffing model I've described is correlated with lower rates of surgical delivery.  There are plenty of doctors in private practice, with admissions privileges at hospitals with different models, and without hospitalists.  Those staffing models are associated with higher c-section rates, for purely practical reasons.  If you have multiple OBs and dedicated anesthesiology on the L&D floor all the time, you can call a section with very little notice.  That means you can afford to do a certain amount of waiting and seeing.  If there's no hospitalist, and nurses have to page the patient's OB to come in for delivery, they have to be aware of the potential for surgery from a much earlier point - they should page the moment they have the slightest indication of trouble, since it can take the OB 30-60 minutes to get there.  And then the OB is much more likely to go ahead and push for surgery, since his or her schedule is already in shambles, and they only get paid if they do something. 

 

Unfortunately, the salaried staffing model is expensive, and only practical where there's a high patient load. 

 

Doctors/Hospitals may be able to bill more for surgical delivery, but that doesn't mean that they *make* more.  C-sections are far more expensive than vaginal deliveries - they involve more professionals (doctors, nurses, and a pediatric team), more equipment, more supplies, more drugs, more janitorial services.  At the end of the day, vaginal delivery, even with all the waiting around, is probably more profitable.  There are always more L&D rooms then there are operating rooms. 

 

Additionally, it's totally unsurprising to me that hospital stays associated with c-sections are longer than those associated with vaginal delivery.  Hospitals are legally required to let you stay twice as long after a c/s as they are after a vaginal delivery. 

 

C-section is correlated with higher risks, but I wonder how many of those risks are related to confounding factors.  I'd love to see a breakdown of indications for c-section, and the outcomes of those sections.  My suspicion is that c/s performed on maternal request, or for indications without implications for maternal health (like breech positioning) have outcomes that are pretty similar to uncomplicated vaginal delivery in the long-term (after the first month or so).  The short-term, of course, is going to look very different.

 

I've had one complicated (instrumental) vaginal delivery and one medically indicated c-section.  I preferred the c-section, frankly.  It was a lot easier for me to deal with the scar on my belly than it was to deal with labial and perineal tearing, both physically and psychologically.  I think most people (me included) would prefer uncomplicated vaginal delivery, but sometimes there comes a point when you realize that it's not going to go that way and you need to redo your math.  When DS was born, I was really grateful to the OB who "let" me push for five hours, with a failed epidural and a mounting fever.  After DD's birth, I realized that some things about DS's arrival were really dumb and dangerous.  I should probably have had a c-section.  In the end, everything turned out fine (after the first month or so), but there were some significant risks to both of us, which I would not choose to run again.  I wish I hadn't been so unreasonably frightened of surgery.

 

Overall, I think we women and babies would benefit from more frank, accurate, unemotional discussions of c-section.  We largely can't make our decisions about how we deliver on the basis of statistics, we have to consider our own situations, and we won't necessarily even know what those situations are going to be until we're in them.

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#92 of 105 Old 05-16-2012, 09:23 AM
 
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Overall, I think we women and babies would benefit from more frank, accurate, unemotional discussions of c-section.  We largely can't make our decisions about how we deliver on the basis of statistics, we have to consider our own situations, and we won't necessarily even know what those situations are going to be until we're in them.

MeepyCat, I love your whole post, but especially this. C-sections arise out of so many different individual situations. Let's find models of care that can help all women have better births, even when really difficult decisions are inevitable and trauma is unavoidable.


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#93 of 105 Old 05-16-2012, 09:25 AM
 
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#94 of 105 Old 05-16-2012, 09:39 AM
 
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Why doesn't a woman who wants a home birth with a midwife deserve competent care?  Who is putting those barriers up?  

 

I had my children at home, 1970s.  My mother had her children at home, 1950s.  Why should any one tell a woman where to deliver and what is safer for her?

 

Miriam, I think I am not expressing myself clearly, or maybe you are not understanding my meaning.

 

I believe ALL women deserve competent care. I believe that home birth with a midwife is the best care choice for many women, but not for all. I believe that many barriers exist the prevent women from choosing a home birth or their best model of care. There are financial barriers, insurance hurdles, legal obstacles. Women can be limited because of their geographic location or their socioeconomic class or the maternity leave policies of their workplace. There is racism and homophobia and prejudice against women with disabilities. I'd like to see us work to remove those barriers.

 

Why should any one tell a woman where to deliver and what is safer for her? No one should. All women should have access to quality care, and should have the tools to assess for themselves what the best care is for them. I'm not arguing anything different.

 

I'm just trying to say that some women will birth in hospitals under the care of OBs, and some women who want to have home births or work with a midwife will be transferred because of complications. Those women shouldn't be thrown to the dogs. Good care should exist everywhere, and OBs and hospitals should be held to high standards. In my opinion, doing so doesn't undermine homebirth or midwifery in any way.

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#95 of 105 Old 05-16-2012, 09:54 AM
 
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Miriam, I think I am not expressing myself clearly, or maybe you are not understanding my meaning.

 

I believe ALL women deserve competent care. I believe that home birth with a midwife is the best care choice for many women, but not for all. I believe that many barriers exist the prevent women from choosing a home birth or their best model of care. There are financial barriers, insurance hurdles, legal obstacles. Women can be limited because of their geographic location or their socioeconomic class or the maternity leave policies of their workplace. There is racism and homophobia and prejudice against women with disabilities. I'd like to see us work to remove those barriers.

 

Why should any one tell a woman where to deliver and what is safer for her? No one should. All women should have access to quality care, and should have the tools to assess for themselves what the best care is for them. I'm not arguing anything different.

 

I'm just trying to say that some women will birth in hospitals under the care of OBs, and some women who want to have home births or work with a midwife will be transferred because of complications. Those women shouldn't be thrown to the dogs. Good care should exist everywhere, and OBs and hospitals should be held to high standards. In my opinion, doing so doesn't undermine homebirth or midwifery in any way.


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#96 of 105 Old 05-16-2012, 10:21 AM
 
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#97 of 105 Old 05-16-2012, 03:25 PM
 
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Originally Posted by CI Mama View Post

 

I agree that the world would be a better place if there were more trained, competent midwives in it, and if there were fewer barriers to women choosing a midwife for their prenatal and birth care.

 

But there will always be women for whom a hospital birth with an OB is the only reasonable choice, and we deserve competent care, too. I don't think it's outrageous to expect OBs to understand and support natural birth, as well as being versed in procedures such as c-section, and I think that OBs should be held to high standards of quality, compassionate care for women.


True, I was being a bit glib.


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#98 of 105 Old 05-17-2012, 06:17 AM
 
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(?) Have no idea what that means; it would be nice if people did not use vinaculars that are understood between them. This impedes communication.

 

Being in the homebirth movement since I was born, over 60 years, I can tell you that when I was born, neighbors wondered if my parents were poor and could not afford a hospital delivery.  That has changed. Why?  Now women cannot afford a homebirth because their insurance will not cover it. Many parents choose a job based on the maternity benefits. 

Actually, I think this represents a very narrow point of view.  I know of several families who have insurance and have birthed in hospital and are struggling to repay the hospital bills, myself included.  And families without insurance struggle even more.  Homebirths are expensive, as are hospital births, and the financial differences depend upon individual situations.  I don't know if I've heard of anyone choosing a position based on maternity benefits, but rather, overall health benefits seem to be a deciding factor.

 

Hospitals are institutions; as such they are run for the convenience of the people who work there.  Delivering mothers who think they are #1 in a hospital setting are kidding themselves.

 

 

The birth framework has not always been the way the birthing population sees it now. Ask yourself why how things got this complicated and who benefits from this complicated system and confusion.  Mothers certainly do NOT benefit from the changes I have seen in maternity care.  Why could a woman deliver in a hospital in 1960 and stay for seven days for under $100?  Many owomen looked forward to being waited on in bed and the rest they were afforded.  Insurance did not cover maternity benefits then since it was not considered the result of an accident.  This was the days of the babyboom, so the maternity wards and nurseries werefull.  Now hospitals do more than 50% surgical deliveries and push mothers out within 48-72 hours, and charge upwards of $15,000-$30,000 at least.

The financial changes you describe don't just apply to hospital stays for births, you know.  Once upon a time, doctors made home visits and expenses were generally affordable.  The changes in costs for hospital delivery & care reflect a growing trend in expenses for medical care in general and aren't just about women and birth.  They are about insurance companies and a growing profit margin.  So I'm not sure what that has to do exactly with the subject at hand.  If you want to rail against costs, take a look at the people who can't afford dialysis or cancer care as well. 

 

When you say most women would prefer the hospital model, you do know that hospital delivery is quite a recent development in human history and it is controversial as to whether this is an improvement.  Preferring a hospital delivery is more of a cultural development, not improvement in health and outcome.  I worked hard with consumer groups in the 1970s and 1980s to put ABCs and L&Ds in maternity wards only to see them never used and closed since doctors risked all of their patients out of them; doctors simply are not comfortable working in them. OBs/Surgeons are not trained that way.  In that same medical center, the head of OB/GYN said that there is NEVER a reason NOT to to a caesarean section. That was 1979. Things have not changed and have become worse.

I didn't see where anyone said "most women.. prefer the hospital model."  I also thought that most hospitals have separate L & D facilities. 

 

When I had my children I had a midwife; she came to my home each time with just her hands, experience and a few items she could use at home - I never needed a stitch, yet had I been in a hospital with a posterior, deflexed head with asynclitism, I would have had my baby and subsequent children surgically.  In the state I delivered, a midwife could legally practice if she had passed a state test, but that test had not been proctored for over thirty years - why? Would the state medical association have something to do with that?   Obviously there was a need for midwives - especially in the rural areas. There were many lay midwives in practice in the rural areas.  Every once in a while there was legal action against one of them for something that OBs would line up around the block at any courthouse and defend one of their own, but would toss a midwife to the wolves.  

Aren't you fortunate to have had a choice about where you birthed?  I'm happy your births went well, and you had a choice of where to deliver. 

I needed and wanted to deliver in a hospital facility, for multiple reasons, and I know how extremely fortunate we were to be able to find and afford a good obstetrician.  I also realize that it's truly a sad state of affairs that not everyone has a choice of health care providers or the ability to birth at home. 

Also, I really resent upthread when you stated that "many" women have cesareans as a matter of "convenience."  I don't know where these people are, but I've never met anyone who actually wanted a cesarean.  I've met quite a few who felt they were medically necessary, and a few who felt as though they were coerced into having one, but no volunteers for convenience Frankly, that sort of statement is condescending and a little bit tacky. 

In my fantasy world, I'd really like to see people advocating for choice and supporting the choices other women make, or supporting medically necessary procedures, or simply listening and not judging.  The safety of c-section, as was brought up in the original post, is something that happens on a person-by-person basis.  I think when we categorize it as safe for everyone or not safe for everyone, there's an element of judgey-ness brought into it-- what may be true for one woman isn't necessarily so for another, and that's why this is such a difficult conversation to have, you know?

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#100 of 105 Old 05-17-2012, 01:25 PM
 
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I know that there are plenty of L&Ds.  My point is that if a hospital has an L&D, it is rarely used.  

 

Miriam, this statement confuses me greatly.  The only hospitals I know of that do not have L&D units are those that don't do obstetrics at all (which is, I admit, a growing number, but those hospitals transfer laboring patients, the only deliveries they do are precipitous ones in the ED).  Those units are in constant use, and all laboring patients are sent there.  So I can only think that you mean something by L&D that the rest of us don't.  Could you please explain?

 

Homebirth is not necessarily cost effective - it's cheaper, in monetary terms, if you consider *only* the cost of the delivery, and if the delivery goes smoothly.  If things don't go well, the costs mount exponentially and instantaneously.  Furthermore, home is an environment in which there is no chance of pain relief, which many women want, and which they should be able to get.

 

It's hard to have this conversation when you insist that women who want ceseareans, or who schedule them in advance, are deceived, misled, or frivolous, without considering the possibility that they're educated, informed, and doing the best they can to deal with the challenges of their lives.

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#101 of 105 Old 05-17-2012, 02:02 PM
 
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Miriam, this statement confuses me greatly.  The only hospitals I know of that do not have L&D units are those that don't do obstetrics at all (which is, I admit, a growing number, but those hospitals transfer laboring patients, the only deliveries they do are precipitous ones in the ED).  Those units are in constant use, and all laboring patients are sent there.  So I can only think that you mean something by L&D that the rest of us don't.  Could you please explain?

 

Homebirth is not necessarily cost effective - it's cheaper, in monetary terms, if you consider *only* the cost of the delivery, and if the delivery goes smoothly.  If things don't go well, the costs mount exponentially and instantaneously.  Furthermore, home is an environment in which there is no chance of pain relief, which many women want, and which they should be able to get.

 

It's hard to have this conversation when you insist that women who want ceseareans, or who schedule them in advance, are deceived, misled, or frivolous, without considering the possibility that they're educated, informed, and doing the best they can to deal with the challenges of their lives.

Agreed. I wonder, if one supports "birth choice" why doesn't one also support a woman's choice to birth in a hospital? To have an epidural? To have an induction? To have a C-section? If a woman makes an informed choice, should that not always be supported? Or do we only support people who make decisions identical to ours?

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#102 of 105 Old 05-17-2012, 02:48 PM
 
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#103 of 105 Old 05-17-2012, 05:46 PM
 
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Your ignorance of homebirth and its practice is showing.  

 

It seems to me that MDC has been hijacked by a large group of hospital public relations corporations.  If you want to defend hospital birth as the norm, why are you on a natural birth discussion board?

 

When a woman desires the list of interventions with an informed choice you have listed, every OB/GYN will line up to defend her choice, so you have lots of support and do not need it from me.  Meanwhile, homebirth choices are OK, but go find yourself a midwife - go on woman - you can have your choice and you are on your own. Depending on where a woman lives, that can be a daunting task, so many give up.

 

  I never thought I would have to defend homebirth as a choice here, on Mothering.com of all places. 

Are you talking about me? I've been here almost as long as you have. Why on earth would you think a member that has been here for 8 years works for a hospital? I am a mother by occupation, and have been for 10 years. Perhaps I'm also an educated woman who isn't afraid to ask difficult questions.

 

I'm not talking about support from OB's, but from other women, which is vitally important to all mothers. So, if a woman chooses to give birth in a hospital with interventions, but otherwise she is an AP natural mother, you will not support her? I believe there is very little support for a woman like that. She's too "hippie" for other moms, and isn't "good enough" for MDC. Where does she go?

 

As for the second part of the paragraph where you say "you can have your choice and you are on your own. Depending on where a woman lives, that can be a daunting task, so many give up." Does that mean that you support legislation and governing bodies over midwifery? Because if not, then how is a woman to find a good midwife? Physicians have review boards and you can look up their lawsuits and any disciplinary actions, plus, if they screw up badly or often enough, their medical licenses are revoked. There are also nationwide standards with regards to their education and training. Is this what you want for midwives?

 

I don't think anyone is saying you have to defend homebirth, but rather saying that we should support all women who are making educated choices, and not shoving them on the fringe with insults because their choices or life experience are different from yours. Every mother has a different story. None is better than the other.

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#104 of 105 Old 05-17-2012, 06:02 PM
 
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I'm still hung up on L&Ds being rarely used in hospitals.  What does this mean?


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#105 of 105 Old 05-18-2012, 04:09 AM
 
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I'm still hung up on L&Ds being rarely used in hospitals.  What does this mean?

I think this means that she hasn't had a baby in 20 years, and none of them were in a hospital.

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