The truth about why we treat pregnancy as a disease in America
The Psychology Of Prepared Parenting – Weekly blog by Columbia Teacher’s College Student Intern Erica Russo
So why is it that it appears that the psychology of motherhood is overlooked in the medical field? My father, Armando Russo, an OB/GYN, has authored this post in response to the last post, “How sonograms influence the interpsychic experience of pregnancy”:
Unfortunately, having a baby in America is not an easy thing to do. I am not referring to access to women’s care, which can be a problem in and of itself, rather, I am talking about the obstetrical care.
In an ever-increasing misguided culture of “obstetrical interventionalism”, pregnancy has become a disease in America. I am not kidding. As a practicing OB/GYN for the past 30 years, I have seen countless women labeled as “high risk”. Generally, this means more tests and then, even more tests. Sometimes we are correct in our assessment, and sometimes we are wrong. Roughly, 90% of all expectant mothers have no problem at all unless we fabricate one.
Obstetrics providers do not like to be wrong. (Note: Obstetrics providers can be physicians or non-physicians – obstetricians, family practitioners, nurse midwives, nurse practitioners and physician’s assistants). We, obstetricians, especially do not want to be wrong, so we over diagnose and over treat. We practice defensive medicine as it is often referred to. Overtreatment can and does lead to complications for the expectant mother and eventually for the baby.
As a result, too many women are delivered by a cesarean. Generally, vaginal birth is safer for the mother but can be more traumatic for the baby. The opposite is true for a cesarean. If we identify a maternal problem, sometimes the baby is delivered early and the baby must spend time in neonatal intensive care at upwards of $1,000.00 per day. Here the reader might ask, “How did we get to this point”?
I believe the answer lies in the belief that we can avoid untoward problems that occur in the neonatal period and later if we subject expectant mothers to a slew of tests during their prenatal care and when they are in labor. This statement is both true and false.
Let’s begin with prenatal care. The monthly, bi-monthly and then weekly prenatal visits were first proposed and adopted to identify common problems. Prenatal testing also involves a slew of genetic screening and testing which is offered to everyone. Screening tests are administered to a general population to weed out people who may have a problem. They are not definitive. For example, we offer “carrier” testing for cystic fibrosis, Canavan’s disease, Tay Sachs, inherited anemias, spina bifida, and trisomies (Down syndrome), to name a few. In addition, any woman can have a diagnostic test (i.e., a test that is intended to actually determine whether or not a problem exists). Then we have ultrasounds. We do ultrasounds for establishing the gestational age and due date. We have ultrasound to get a picture of fetal anatomy, i.e., to identify features consistent with known birth defects or genetic anomalies.
All of this testing is intended to establish whether or not the pregnancy is normal. However, we cannot dismiss the psychological stress all this testing has on an expectant mother. We do not have much information for this one area.
If a woman is unfortunate to get the “high risk” tag, she will need to go to the office or hospital for “non-stress” testing once or twice per week until delivery.This is anything but non-stress for the mother. The situation is no less stressful when an expectant mother is admitted to a hospital to have her baby. We confine and limit – all for the sake of “monitoring “. Why? Well, the road to hell is paved with good intentions.
Forty years ago, electronic fetal heart rate monitoring (EFHR) was promoted by its developers and equipment manufacturers with the well-intentioned belief that this technology could identify fetuses in utero that had a lack of oxygen (hypoxia) and were likely to develop neurological developmental deficits including cerebral palsy. The initial studies were promising, so this technology rapidly became the standard of care in American obstetrical practice. The problem is that this was wishful thinking. When the properly designed studies were eventually done, EFHR was shown to fail both as a screening and as diagnostic test. In scientific terminology, it is neither sensitive nor specific enough to be valid.
The most striking effect of EFHR has been to falsely identify fetuses at risk and, as a result, the incorrect diagnosis of “fetal distress” has been one of the leading causes of our increased cesarean birth rate. In 1970, the chance of having a cesarean was one in ten. Today, it is one in three. EFHR has misled. It cannot reliably tell us what we want to know if we utilize it indiscriminately. The problem is that it is so entrenched in the culture of birthing, we cannot stop using it.
Are we insane or are we too frightened to relegate EFHR to the trash heap? I suspect it’s the latter. We have sent the wrong message to American women and the public at large that we can identify all sorts of problems and can somehow deliver a perfect baby each time. Therefore, it is reasonable to conclude that if we don’t, we must have made an error. The most common reason obstetricians are sued is alleged neurological injury to the baby for failure to perform a timely cesarean delivery. The second most common is a birth injury (brachial plexus injury) resulting from a trapped shoulder at the time of vaginal delivery. Even a perceived error in obstetrics is costly.
A 2010 study from the American Medical Association reported, “The specialties with the highest rate of medical malpractice claims were general surgery and obstetrics/gynecology, with nearly 70% of physicians in those specialties facing suits during their careers.” The study also reported that 65% of claims are dropped or dismissed, and another 30% are settled or decided via an alternate dispute method. Only 5% of claims actually go to court — of those, 90% are decided for the physician.
Even a win can be costly. Average costs to defend against a claim were just under $40,700. For claims that were dropped or withdrawn, it cost an average of just over $22k to defend, whereas cases that go to trial average more than $100k to defend. More frustrating still is the rate of claims seems to have little correlation to actual malpractice. (Note: malpractice is defined as a deviation from the standard of care for which the practitioner has a duty to a patient and damages resulted from action or inaction. Malpractice is not just a poor or unexpected result). The AMA researchers found that among closed claims, 3% of patients had not suffered any injury and in another 37%, there had been no error. Worse: Many injured patients and wrongly accused doctors do not get true justice. The researchers found that 27% of claims are paid despite the doctor not making an error. At the same time, 27% of patients who suffered from an error receive no compensation.
For all the above, it is no wonder that pregnancy in America is treated as a disease. It is stressful for the expectant mother, the couple and the care provider. We need to change this.
Armando Russo, a Fellow of the American College of Obstetricians and Gynecologists, is a practicing OB/GYN in the South Jersey region with over 30 years experience. He is the President and co-owner of Cumberland OB/GYN, PA in Vineland, NJ, and the Department Chair of the Department of Obstetrics and Gynecology at South Jersey Regional Medical Center, where he was the 2009 recipient of the Physician of the Year Award.