7 Ways We Can Dramatically Improve Childbirth in America
August 28, 2019
While childbirth in many other developed countries continues to improve, the maternal mortality rate has risen in the U.S. Here are 7 ways we can begin to reverse this alarming trend.
More than a decade ago, NPR published the story of two American mothers who chose to give birth in France, which was recognized by the World Health Organization (WHO)Trusted Source as providing some of the best overall healthcare in the world.
The women detailed the struggles they had receiving and paying for prenatal care in the United States, contrasted against the easy and seemingly joyful experiences they had receiving healthcare and delivering in France.
Today, France maintains its reputation as being one of the best places in the world for women to give birth.
Meanwhile, the maternal mortality rate has risen in the United States — a trend that differs from nearly all other developed nations.
Rates of hypertensive disorders and postpartum hemorrhage are on the rise, according to the Centers for Disease Control and Prevention (CDC)Trusted Source.
And while pregnancy makes it easier to receive state-funded healthcare, most women lose that coverage shortly after giving birth, leaving them with few options should complications arise down the line.
Between fights with insurance companies, a dramatic rise in C-sections, and our concerning maternal mortality rates, there’s no doubt childbirth in the United States has room for improvement.
But what exactly should those improvements entail? Here are 7 ways we could dramatically improve childbirth in America.
Doulas aren’t healthcare providers, but their services are still vital to improving birth outcomes according to Dr. Jackie Stone, OB-GYN, of the Maven Clinic in New York.
“Research shows that women who use doulas during labor and delivery have lower rates of C-section,” she told Healthline.
While she acknowledges that doulas aren’t a replacement for a medical provider, she explained they are beneficial because they act as “a personal advocate and emotional support coach.”
This is a stance supported by the March of Dimes, who put out a position statement arguing for “increased access to doula care as one tool to help improve birth outcomes.”
Gene Declercq, PhD, agrees. A professor of community health sciences and assistant dean of doctoral education at Boston University, he’s also a researcher who focuses on maternal health outcomes in the United States.
Declercq told Healthline that doulas can be part of a system actively reaching out to women and helping them through the healthcare process.
“Women need to feel like they have a place to go to get help, someone who is knowledgeable, who can guide them through that system that everyone finds confusing,” he explained. “It’s not just poor people who find it confusing. I find it confusing. It’s not surprising people can get lost in a system like that.”
In a profit-driven system often run by insurance companies and business leaders setting limits on the amount of time doctors can spend with their patients, or dictating how many patients a doctor should see in a day, one thing that’s often lost is a genuine relationship between the patient and provider.
When the time isn’t allowed for a doctor to truly get to know and listen to their patients, important details are sometimes missed.
“I think the most important way to improve the experience for women, and by extension their babies, is by listening to and developing relationships with our patients,” Dr. Mary D’Alton, obstetrician and gynecologist-in-chief and chair of the department of OB-GYN at New York Presbyterian/Columbia University Irving Medical Center recently told Healthline.
She explained that her father was a general practitioner who always used to say, “Listen to the patient, she will tell you what is wrong with her.” It’s a statement she says she’s found to be true in her own practice.
“It is a critical part of care that patients feel that they are empowered to speak up and ask questions about their health and the health of their baby,” she said.
It’s been common practice in the past for women who have received C-sections to then also receive a prescription for opioids.
But with rising concerns about opioid use in the United States, practitioners and researchers alike have begun to question the implications of giving so many women what can ultimately be a dangerous prescription.
New research out of the journal Obstetrics and Gynecology brings to light a few other reasons OB-GYNs should consider backing away from opioid use after C-section.
The study, comparing over 4,500 women who had scheduled C-sections, found that a reduction of opioids post-surgery improved recovery rates — allowing patients to be up and walking sooner than those who were given the medication.
As part of the Massachusetts review committee looking into cases involving opioids post-cesarean, Declercq said he believes strongly in the need to improve the communication system between doctors and patients so that doctors can be especially cognizant of not prescribing opioids to those who may have previous addiction problems.
“There’s a continuity of care issue with doctors who don’t always realize the patients had a previous problem. This isn’t a case of people being bad, it’s a bad communication system,” he said.
In the United States, women of color have 3 to 4 times greater risk of dying during childbirth than their white counterparts.
This is even when factors such as socioeconomic status and education are removed from the equation.
D’Alton explained, “The disparate outcomes for African American obstetric patients are very clear and have been attributed to the impact of toxic stress and implicit (or explicit) bias in care.”
Stone believes that the increased risks women of color face won’t be resolved until we first find a way to tackle those implicit and explicit biases in healthcare.
“Our healthcare systems — from medical education and residencies to hospital systems — need to focus efforts on how to train healthcare professionals to understand their own biases as well as additional research into why this dichotomy exists,” she said.
Research supports her position. In fact, a report in BMC Medical EthicsTrusted Source concluded there’s a “need for the healthcare profession to address the role of implicit biases in disparities in healthcare.”
The National Institute of Health (NIH)Trusted Source also ranks eliminating health disparities as third of its top 5 priorities.
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“Obstetric complications are rare, but can become life-threatening very quickly,” D’Alton said. “Because of this, providers need training in how to respond to them in a systemic, standardized way.”
So far, these standardized metrics for how to respond to various complications aren’t widely available throughout the field of obstetrics.
“Studies show that 60 percent of maternal deaths in the U.S. are preventable, with most deaths occurring from infection, hemorrhage, or cardiac events,” Stone said. “While other specialties have put in place metrics to reduce morbidity and mortality, this has not happened in obstetrics.”
As examples, she pointed out that there are standard amounts of time a patient with pneumonia should be started on antibiotics or a patient suffering from a heart attack should be sent to a cath lab.
“There are few hard and fast metrics for obstetrics to reduce maternal mortality,” she said.
But that doesn’t mean it can’t be done. In fact, California has reduced its maternal mortality rate by 55 percent.
Stone said this was accomplished by collecting records from every maternal death to look into causation. “They then created manuals or guidelines for every obstetric emergency and situation from preeclampsia to obstetric hemorrhage and ensured the hospitals had on hand the correct supplies.”
According to Declercq, one of the biggest mistakes we make is working hard to bring women into the healthcare system only when they’re pregnant.
“The states that refuse to expand Medicaid systems are, not surprisingly, the ones with the worst outcomes,” he told Healthline. “And it’s because they don’t focus on women’s health as a whole.”
The problem with this, he explained, is that women who haven’t received care in years may come into the system during pregnancy with a long list of health complications that haven’t ever been addressed before.
These previously untreated issues can then contribute to negative health outcomes throughout the pregnancy.
And then, even if everything goes according to plan throughout labor and delivery, most of these women lose their health coverage within 60 days of giving birth. But maternal mortality rates include deaths that occur up to a year after birth.
“If you look at overall death rates — not just pregnancy-related — for women 25 to 34, the biggest group of women having children, their death rates have gone up 22 percent since 2010,” he explained.
Women as a whole aren’t getting the care they need. And yes, the negative impact of that then expands to pregnancy outcomes.
“Women’s health matters — whether they are pregnant or not. We need to bring people into the system,” he said.
Pregnancy can be a scary and isolating time for some women. And in the rushed world of healthcare, they can sometimes feel as though they aren’t allowed to speak up for themselves.
But both D’Alton and Stone want women to know they have choices.
D’Alton said that one of the most important things a woman can do for herself to ensure a happy pregnancy outcome is “choosing a hospital that can manage your particular risk profile.”
She also said she worries that “there is an increasing lack of education happening during pregnancy about childbirth, and I think learning as much as you can beforehand better positions you to respond and make decisions in real-time.”
Additionally, Stone encourages women to research their practitioner’s C-section rate. “If they find that the rate is high, I encourage them to dig deeper to see if this is due to the provider caring for high-risk patients versus personal practice style. Does the provider do a lot of C-sections around 5 p.m.?”
Women do have choices in this process, and finding a provider they feel comfortable with can be one of the ways to ensure the best possible outcome.
However, D’Alton also encourages women to put this all in perspective.
“The awareness about maternal complications of pregnancy is so important, but we don’t want women to become overly anxious about the risks. It’s important for their health and their baby’s health to seek out the care that they need for their particular situation and to find providers they can trust,” she said.
She explained that many in the field of obstetrics are working hard to address the systemic barriers that lead to a distrust in obstetric care or to non-standardized responses.
“That is an effort that we will continue until no woman dies or experiences a complication from a preventable cause,” she said.