One of the most amazing things about writing for this blog is that no sooner do I mention something untoward or dangerous and someone rushes to demonstrate it.
Yesterday I wrote about the way that a low index of suspicion for pregnancy complications leads to maternal deaths. Today, Consumer Reports publishes a ham handed piece, Childbirth: What to Reject When You’re Expecting, by Tara Haelle that obsesses about process without giving any serious consideration to the only thing that really matters, outcome. It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.
Haelle starts with the usual framing:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.[/pullquote]
Despite the benefits of a healthcare system that outspends those in the rest of the world, infants and mothers fare worse in the U.S. than in many other industrialized nations…
Infants in this country are more than twice as likely to die before their first birthday as those in Japan and Finland, and America lags behind nearly every other industrialized nation in preventing mothers from dying due to pregnancy or childbirth…
Why? There are no doubt many causes. But one likely contributor may be that medical expediency often takes priority over the best outcomes and evidence-based treatments…
That’s a brutal assessment requiring copious evidence to support it. Haelle and Consumer Reports provide none.
And in this setting in particular, that is inexcusable.
What is most ugly about this is that it ignores the fact that black women and babies are disproportionally affected, with death rates FOUR TIMES HIGHER than everyone else, far exceeding that of every other minority group,
We will never improve outcomes for black babies and women if we pretend that mortality is primarily a problem for privileged white women looking to craft a “birth experience.”
We will never reduce perinatal and maternal mortality as far as possible if we lie to ourselves about the real causes.
To my knowledge, there is NO EVIDENCE, zip, zero, nada, that perinatal and maternal deaths are caused by medical expediency. But that doesn’t stop Haelle or Consumer Reports.
They trot out the usual hobby horses for condemnation: the C-section rate, the induction rate, continuous electronic fetal monitoring, episiotomies, epidurals and sending babies to newborn nurseries.
These are processes, NOT outcomes. They affect the birth experience far more than they affect whether babies and mothers live or die. No matter. Consumer Reports and Haelle only mention death rates to imply that interventions cause death, not in any serious effort to prevent deaths.
Look at the reasons why mothers die:
How is obsessing about process going to have an impact on the most common reasons for maternal death, cardiac and other chronic diseases? It isn’t.
What about infant mortality?
How is obsessing about process going to have an impact on the most common causes of infant death, congenital anomalies, prematurity (generally extreme prematurity), and complications of pregnancy. It isn’t.
Though there is no evidence that medical expediency kills babies and women, there is considerable evidence that medical complacency, assuming that pregnancy is inherently safe when it is actually inherently dangerous, does kill.
As noted in the ProPublica/NPR report about maternal mortality:
Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.
California set out to reduce maternal mortality and the California Maternal Quality Care Collaborative created “tool kits” for providers:
The first one, targeting obstetric bleeding, recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of the common practice of “eye-balling” blood loss, which often leads to underestimating the seriousness of a hemorrhage and delaying treatment, nurses learned to collect and weigh postpartum blood to get precise measurements.
In other words, the CMQCC set out to raise the index of suspicion and insistuted drills to deal with emergencies, not offer false reassurance pretending they aren’t happening. The results are very impressive:
Hospitals that adopted the toolkit saw a 21 percent decrease in near deaths from maternal bleeding in the first year; hospitals that didn’t use the protocol had a 1.2 percent reduction. By 2013, according to Main, maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.
Sadly, the focus on process ahead of outcome is not limited to childbirth; it has been extended to breastfeeding and the results there have been even more disastrous.
The Baby Friendly Hospital Initiative, designed to promote breastfeeding (a process), has led to a large and growing number of DEATHS (an outcome). Aggressive breastfeeding promotion, including policies against formula supplementation and mandatory rooming in of babies in their mothers’ hospital rooms have led to an epidemic of infant brain injuries and deaths from dehydration, hypoglycemia (low blood sugar), and babies smothering in or fracturing their skulls falling from mothers’ hospital beds. No matter, the BFHI cluelessly touts breastfeeding rates as if that, in an of itself, is a measure of quality, while studiously ignoring and sometimes aggressively denying the entirely preventable deaths that result.
Process, in both childbirth and breastfeeding, does matter, just like cup holders and interior upholstery matter in cars. But outcome is far more important than process. Consumer Reports should stop pretending that childbirth is safe and the only thing we need to do to improve it is to decrease interventions. That doesn’t mean that we shouldn’t try to reduce C-section rates and the rates of other interventions, just that those efforts should take a backseat to reducing deaths.
