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leo-cullum-expert-witness-new-yorker-cartoon1“Childbirth is something that is primitive, ugly, nasty, inconvenient,” Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo, said. “It takes long, and the idea is we have to make it fast. It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section.”

From an article about C-section rates in Brazil

The World Health Organization has decided that about 6 out of 7 babies should be born “naturally.” How do they know this? Mostly, by making educated (and some less than straightforward) guesses. Fact is that as we doctors have medicalized childbirth, we have complicated the choices women have to make, made childbirth less convenient, and not really improved outcomes all that much. Witness Brazil, where the c-section rate is almost 50% and the maternal mortality rate is 69/100,000 births,  The best country for mothers surviving childbirth is Belarus, where only 1 mother dies per 100,000 births and where 4 out of 5 mothers have a vaginal delivery. Here in the United States, by comparison, 1 in 3 mothers get a c-section, maternal mortality is 28/100,000  and for all we spend we are still #62 in maternal mortality, between Korea and Malaysia.

One school of thought is that all of these c-sections are at least resulting in healthier babies. If only that were true. Although the statistics for infant mortality are a little confusing (some countries don’t count babies below a certain weight and others do), Brazil should have a really low rate with so many of their mothers going to section. By their count, about 12 out of every 1000 neonates die, twice that of America (best is Luxembourg at 1/1000, 3 out of 4 delivered vaginally).

If a high number of c-sections are not particularly good for the mother or the baby, why do so many get done? The National Partnership for Women and Families has debunked some myths and identified some real problems. First the myths:

1) “I want my baby on Tuesday” – Although we would like to believe that consumer choice has something to do with it, only 1% of women who have primary c-sections (a first baby born via c-section) requested that it be done that way.

2) “My doctor says I’m not made for a baby to come out down there” – Though we believe that  women are getting older and more likely to have other medical problems, this is not the case. The evidence is that those women who before 1990 would have had a trial of labor, all things being equal are now being encouraged to go to c-section.

3) “If I do a c-section the patient won’t sue me, especially if things go horribly wrong” – Turns out that the medical system screws up about 1 in every 100 deliveries but only 2% of those lead to lawsuits. Turns out docs are much more influenced by who they chat with in the doctor’s lounge than by actual risk of malpractice claims.

Why so many c-sections? First, women are not encouraged to get in shape for childbirth. We are discovering that the human body deals much better with changes associated with surgery if its owner has it in good shape. This is true for childbirth as well. Women need to be encouraged to be in good physical shape at all times but especially as childbirth approaches. Second, it is important not to rush mother nature. We are finding out that waiting until after the due date to do anything is very important. Obstetrics means “to stand by” and that is what doctors (and patients) need to do. Third is that we are afraid to agree that anything but “once a c-section, always a c-section” is okay. A problem when the primary c-section rate is so high. Fourth, we tend to have a blase attitude towards surgery. We do a lot of surgery in this country and tend to think nothing of it. Obstetricians make a living at it. Along with that  is a belief that nothing bad happens in surgery. Although  c-sections are much safer than they once were, the human womb is not made to be cut open several times and have a baby forcibly removed. Lastly, doctors get paid more for doing a c-section. Less so now in terms of money (it used to be different) but much more so in terms of time (one hour for a c-section as opposed to sitting up with a woman for 12 hours) and increased opportunity cost (ability to do something else with that 12 hours). In the words of one Brazilian who was rushed into a c-section after laboring for 6 hours (less than the average labor takes by half): “He was saying, ‘I was at a birthday party, and I want this done fast because I want to go back and finish my whiskey,’” she said.

To change the c-section rate, then, women will need to take back their bodies from doctors (again). They need to be aware of what the c-section rate is at the hospital they are planning to deliver at and select a doctor and a hospital with a rate below 25%. They need to demand an opportunity to go into labor naturally if at all possible. Mostly, though, they need to prepare for labor physically and mentally. Turns out that only mothers can prevent needless c-sections.

I wrote recently that I did not feel my specialty was threatened by Advanced Practice Nurses and stated why the threat (present since the mid-1990s) had not been made good. There is more evidence in a recent American Medical News that while people may like to shop at WalMart, they are not necessarily looking for health care. The article points out that the Minute Clinic concept is not consistently a break-even proposition and the number of new sites has leveled off. On top of that, many are likely loosing money if you run the math. Why is that? Turns out that the business model of putting a provider among the Kleenexes might work in the winter but isn’t a good idea in the summer. Additionally, these providers are so limited in their scope that even folks that like to consume lots of health care are left wanting. For those that still want to believe that Family Physicians can be replaced, fear not.  “Other clinics are betting that expanding their scope will have some impact. Many are expanding to include wellness services as well as chronic disease management to help spread the business year-round.” I only hope they are up to providing quality care amongst the bowel care products.

While at the Alabama Academy of Family Physicians meeting this weekend, the discussion turned (as it is in a lot of places) to health care reform, the climate in Alabama, and whether primary care can survive the next 10 years in Alabama. As I have chronicled the environment for Family Physicians in private practice is not very favorable and Medicaid in Alabama is inherently unstable. To give ourselves yet something else to worry about that we can’t control, the conversation around the table moved the suspicion that the major payors (Blur Cross and Medicaid) are attempting to transform the care delivery system by dropping the reimbursement so low that non-physician providers will be the only ones who can afford to provide primary care services.

This concern has been around at least since the HMO “revolution”. The New York Times ran an article detailing the demise of the primary care physician and the rise of non-physician primary care in 1997. On the service, it is an appealing concept. Advanced practice nurses take less time to train (5 years with undergrad counting) than physicians (7 years post-baccalaureate). To the untrained eye as well as to the partialist physician, what I do seems “so easy a caveman could do it” so why should we waste physician resources on primary care? Lastly, patient satisfaction is always higher for visits to advanced practice nurses when reported than it is to physicians.

 So why am I not unemployed? As my friend Bob Bowman has posted, Family Medicine Advanced Practice Nurses spend only 3.5 years in primary care before moving onto something else. They will constitute at best only 12% of the primary care workforce. Expansion of training to take advantage of the more rapid training cycle without fundamental change in the delivery system will result in more Advanced Practice Nurses but no more in primary care practices. It is true that Advanced Practice Nurses are likely to practice in rural areas when they go into primary care and this must be captured and expanded upon.

It is true that if 30,000,000 folks who do not currently have access are given access, there will be a signficant unmet need for primary care. As Lori Heim, the president of the American Academy of Family Physicians stated, our  common goal of improving access should dictate the relationship between physicians and Advanced Practice Nurses. I suspect there is enough business in the new model of healthcare for both groups.