I wrote last week about Dr. Neel Shah’s piece in The New England Journal of Medicine musing on the desirability of homebirth.
Dr. Shah piously presents his musing as a way to save women from overtreatment from C-sections, which he derides as like an airbag exploding in a woman’s face. Apparently, Dr. Shah views the promotion of homebirth as a way to save money. On Thursday I noted that Dr. Shah never mentioned (and seemed to be unaware) of the multiple studies and datasets that show that US homebirth has a death rate up to 800% higher than comparable risk hospital birth. He never mentioned (and seemed to be unaware) that in contrast to the UK, the US has a two tier midwifery system with the bulk of American homebirths attended by grossly uneducated, grossly undertrained second tier midwives.
On Friday I asked what message we send to women when we derided C-sections as unmitigated disasters and argued that we convey the message that women who undergo C-sections have failed, have been failed by their obstetricians, or both. That’s hardly a message of support.
Today I’d like to ask another question:
What message do we send to women when we advocate saving money on healthcare by undertreating their agonizing pain? Homebirth doesn’t just save money on over treatment; it saves money by undertreatment, preventing women from getting the most effective form of labor pain relief, an epidural.
We send the ugly, morally repugnant message that, whereas we would never contemplate saving healthcare dollars by undertreating men’s pain, we should not merely permit, but we should encourage saving money by refusing to treat women’s agony.
After all, they’re just women; presumably they’ll get over it. You know what they say: women forget the pain of labor once they see the baby. After all, women’s agony in childbirth is natural, so why should we waste our health dollars ameliorating it? After all, think of how much we could improve healthcare financing simply by forcing women to give birth at home and letting them scream their throats raw.
That’s the odious subtext of saving money by promoting homebirth; women’s excruciating pain is not “worth” treating.
How have we reached the point where women’s pain is not worth the cost of relieving it?
We’ve had lots of help along the way.
To being with, most of us have been raised within religions that view women’s pain in labor as appropriate “punishment” for having sex (even within marriage).
That view received a secular gloss with the advent of the philosophy of natural childbirth. Grantly Dick-Read was explicit in his view that primitive (read: black) women didn’t have pain in childbirth because they understood that their primary role in life was to bear and raise children. Those uppity white women of the wealthier classes, had been “over-civilized” by their educations and their desire for legal and economic emancipation. Their pain in labor reflected their refusal to accept their lot in life. The fear-tension-pain cycle that Dick-Read conjured from whole cloth reflects his view that pain in labor was punishment for women who didn’t wholeheartedly welcome the relegation of women to baby making factories.
Lamaze, the competing philosophy of unmedicated birth, had its genesis in the Soviet Union in the years after WWII. It was a response to the fact that the USSR could not afford pain relieving medications and, in an effort to compete with the West, created a free alternative: Pavlovian conditioning to convince women they weren’t in pain. This was presented as the socialist effort to make pain relief accessibly to the proletariat, when in reality, it was inaccessible for all.
Midwives, contemporary avatars of the natural childbirth philosophy, have demonized epidurals for a different reason; they can’t provide them and therefore cannot profit from them. They don’t oppose all forms of pharmaceutical pain relief; they’re happy to drug women with nitrous oxide since they can do that themselves, but epidurals are verboten. What’s the difference between inevitably agonizing labor described in the Bible and the “empowering” pain of midwifery approved natural childbirth? Salesmanship.
Is it any wonder then that Dr. Shah (just like the money counters at the British National Health Service) finds it perfectly reasonable to save money by depriving women of the chance for effective pain relief in labor? He’s come of age in a society where women’s pain in childbirth is merely acceptable punishment, and within a medical sysatem where it is being aggressively peddled by midwives as positivly desirable: spiritually fullfilling and personally empowering.
While it may be reasonable to Dr. Shah and other who promote homebirth as a cost saving measure, it is morally reprehensible.
Women’s pain matters.
Treating women’s pain is an ethical mandate.
Saving healthcare dollars by deliberately putting effective pain relief out of reach of women forced to labor at home is immoral.
That Dr. Shah (and others who promote homebirth for financial savings) never even considered this dimension of encouraging homebirth is testament to how far women still have to go in being taken seriously as human beings who have the same right to pain relief as men.
Skeptical OB is not licensed. Nitrous is a far cry from a needle in the back, gal.
Why do you idiots always pick the multiple years old posts to comment on?
(Because they hope, that no one will see their comment?)
It’s a sneaky way to get in the “last word,” and ensure that their comment will be the first one seen.
Why should retired persons maintain their licenses? She’d still be a better choice to help me deliver my baby than the seriously undertrained CPMs.
You’re right! The needles in the back are very different from nitrous oxide; they provide superb pain relief for most without any “drugged” feeling, and very little (if any) of the medication reaches the baby. Hurrah for epidurals.
You’re right! My “needle in the back” took away 100% of the pain from my contractions. And I was completely awake, and my babies were completely alert and able to breastfeed withing the first hour. I wouldn’t want to be drugged and drowsy from nitrous.
I’ve done it 7 times and would hardly describe it as painless but not agonising. I don’t like the way people on here are so quick to dismiss the notion of ‘pleasurable birth’ but so keen to embrace the concept of it being agonising. The words on both ends of the spectrum are divisive and polarising.
I don’t know that anyone here has dismissing birth being pleasurable. Orgasmic birth? Sure, people have dismissed that. But not pleasurable.
Personally, I had back labor with my second. It was agonizing. There was a point, for several hours, where I just withdrew into myself. I didn’t move, I didn’t speak. It was horrible. It was just me and the pain. There was no getting away from it.
That’s nice for you. For me labor pain was agonizing. For many women labor pain is agonizing. For very few is it orgasmic. Claiming that the words “agonizing” and “orgasmic” are equally valid (or invalid) as descriptors of labor is like saying that both people who claim that the world is flat and those that claim it is round are wrong because the earth’s surface is uneven so it isn’t a perfect sphere.
That is a failed attempt at analogy. It doesn’t need analogy. Some women have pleasurable births. Some have the opposite. Hospital environments increase pain and danger either way.
No, hospital births greatly reduce danger.
Hospitals are safer. Most women do not find childbirth pleasureable. Congrats if you’re one of the few who do, but your experience is decidedly rare. Why else do you think the ancients thought it was a punishment from God?
All my births were without pain relief. Knowing now how they ended up, I wouldn’t change those decisions if I had the chance. My births were very pleasurable in retrospect- my babies came safely and easily, whole and healthy without trauma or the need for rescue. In the moment, I had anxiety until delivery was complete and I heard that first glorious cry and knew all was well.
I have also sat through about dozen births as a support person, some without pain relief, some with epidurals, some with IV meds. Most of those moms were in agony before getting relief (excepting the one who managed to get a preemptive epidural for her induction- it was her 5th kid and she knew what she was avoiding and how to advocate for herself!), and those who chose epidurals seemed more satisfied than those who got IV meds. All who elected for pain relief found birth much more pleasurable with it.
Suffering from pain in birth is pointless and generally very preventable. Almost all births can be pleasant, if access to interventions that can prevent suffering is available. The task is to identify which interventions are safe, effective, and appropriate for each individual circumstance, and that should be left to those who are actually facing those individual circumstances.
Some women do find it not that bad. Many, perhaps even most women, would say that “agonizing” is appropriate. And women who are in extreme pain deserve the option of pain relief.
…because it IS agonizing. There are a small percentage of women (you among them, apparently) who do not experience much pain at all. Good for you, and congratulations on winning the genetic lottery. Please don’t try to talk the rest of us mere mortals out of pain relief.
I think describing birth pain as agonising is a bit unfair. It’s as far over the other side of the spectrum as claiming it is orgasmic.
It’s pain. People are allowed to find it agonizing. People are allowed to have different thresholds of pain, as well.
And also, unfair to whom? Unfair to birth, to call it extremely painful? It’s a good thing that the process of birth isn’t sentient, and can’t feel slighted if someone calls it “agonizing.”
And there isn’t a single axis continuum of ways that people can feel about birth pain, with both poles being automatically wrong just because they’re at the extreme ends. Truth isn’t always in the middle, for that matter. “Agonizing” is a perfectly adequate word if the shoe fits.
Having been through it twice, I would indeed describe it as agonising. There may be some lucky few who don’t have much pain during labor…would that they were the norm!
It varies from woman to woman, like so many things, but there’s a reason that multiple cultures define birth as being some sort of divine punishment.
I was watching some GAA yesterday, and thinking about John Oliver’s recent piece about US stadiums, and I had a thought.
If someone said “I’ve just read that NFL players live longer than GAA players! We should ban Gaelic football and hurling and replace them with American Football!” it might superficially sound like a good idea.
BUT, if that person didn’t know that they were comparing a amateur sports, where you play for the county you were born in for no financial rewards, while holding down a full time job or that GAA players wear minimal protective gear on the pitch, and they were comparing that to the full-on sports-industrial machine of the NFL they would quickly think that perhaps other factors than the game being played might be influencing the longevity of the players.
Dr Shah is that guy.
He’s trying to get the GAA to play American football, because he hasn’t considered the completely different systems in place.
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Women’s pain is already undertreated in other areas of OB/GYN care here in Canada. Most women in Canada will have access to an epidural, if they choose it, during labor; however every woman I know who has had a c-section has been under-medicated for pain in hospital and sent home with instructions to take regular tylenol and advil as necessary. My father had a hernia repair a few months ago and was sent home with a 3 month supply of percocet. One is major abdominal surgery, the other isn’t. Why is it that the man is sent home with adequate pain control post surgery and the woman isn’t? Especially when the woman has undergone a MUCH more extensive procedure with a longer and more painful recovery.
I also had the *ahem* wonderful experience of getting several cervical biopsies done and an endometrial biopsy done this past Friday. Two days later and I’m still taking two extra strength tylenol and two extra strength advil every 4 hours. I had no anaesthetic during the procedure whatsoever (not even a local). The cervical biopsies sucked, but the endometrial biopsy hurt so bad I vomited (I didn’t even vomit during either of my labors) and almost fainted. Why, in this day and age, do we make women suffer in this way?! You can get sedation for a damn MRI if you are too much of a weenie to sit still for a completely painless and non-invasive procedure, but a woman can’t get some pain relief, let alone sedation, to get a tube passed through her cervix and a hole punched in her uterus?! What a bunch of BS. I honestly don’t care if the big “C” remains a concern, I will NEVER consent to that procedure again unless they knock me out for it.
I wish I had more upvotes to give you. After my C-Section, I was given only Sodium Diclofenac and Paracetamol and told that if I took both of them together I should get sufficient pain relief. What a load of rubbish! The pain relief I got from those meds was just about enough to allow me to sleep; it was nearly a week before I could get out of bed without being in agony. It almost made me glad that my baby was in NICU because it meant that I could concentrate on recovering; I don’t know how on earth mothers of full-term c-section babies cope as they’re expected to room-in and look after their babies from the get-go.
I was thinking of asking for stronger pain relief, but then I heard another mother in my ward asking for co-codamol to take instead of paracetamol and getting a lecture from the nurse about how the medicine would pass to her baby if she breast-fed (which of course she REALLY ought to), how she couldn’t be discharged till she was getting by with only paracetamol and how paracetamol ought to be enough for ‘mere’ post c-section pain. So I never asked.
I developed a hematoma and hoped that this would be a ticket to better pain meds, but no. I got given antibiotics to prevent an infection developing in the hematoma, but no pain meds. And I got plenty of death glares and snide comments from the NICU staff about how I didn’t spend enough time with my baby during the beginning of my recovery.
I’m very happy to be having a meeting with an anaesthetist prior to my ERCS.
One of the things I will mention is that I respond idiosyncratically to opioids.
I don’t really metabolise codeine at all, so get minimal pain relief from it.
I also seem to have a very high tolerance for morphine.
If they dose me according to my weight, my pain will not be controlled. Last time I had surgery I ended up getting almost 30mg of IV morphine in a four hour window to get my pain from 8/10 to 4/10. That is a lot for someone on no regular opioid medication who weighs 45kg.
The staff who know me well, thankfully, know that I just need more than the average bear. I’m not drug seeking and I really won’t ask for opioids unless I need it. The obstetric hospital staff do not know me as well as most of the anaesthetic staff in the main hospital.
The local hospitals have stopped giving Cocodamol to nursing women, substituting Sevredol (morphine) instead. From my last CS I know that paracetamol and diclofenac alone will be inadequate for the first 3-5 days.
Fentanyl and Oxycodone work much better for me, and I’m hoping that the anaesthetist will see the sense in adequately controlling my pain with lower doses of synthetic opioids rather than not controlling my pain or poorly controlling it with heroic doses of Sevredol.
Knowing how long the drug rounds take, I’m going to suggest that they write me up for regular long acting Oxycodone with PRN short acting Oxycodone for breakthrough.
This is not about “pain thresholds”, it is about pharmacokinetics and genetics. Anyone who implies anything else will find that I have absolutely no problem making formal complaints.
It seems like there’s a vicious circle going on here. Post C-Section mothers are only given paracetamol and diclofenac and chastised if they ask for anything stronger, then the next lot of mothers are told “All the mothers who had C-Sections before you were fine with paracetamol; what makes you so special?” if they ask for stronger meds. Where did this idea that post C-Section pain can be managed effectively with just paracetamol and diclofenac come from in the first place? I would suspect the usual ‘normal birth’-ists but I would have thought that they would consider a mother a ‘lost cause’ once she’s had a C-Section and leave her be.
“I would have thought that they would consider a mother a ‘lost cause’ once she’s had a C-Section and leave her be.”
Oh, no, she has to ‘atone’ with EBF, AP, and, of course, a healing HBAC.
That is absolutely insane. I am so sorry that you had that experience. As if being a new mom isn’t hard enough, you had to learn how to be a new mom after major surgery and without adequate pain control. It is disgusting, really, that they made you suffer like that.
I am so sorry you were treated so badly; that is truly awful.
I am also so very thankful for my OB, who doesn’t believe in letting his patients be in pain (unless, of course, they want to–ie, natural birth). I got a 30-day (I think?) script for Vicodin after my CS. I never had to fill it; I suspect my pain threshold’s pretty high, but I didn’t need anything more than ibuprofen once I left the hospital 4 days later.
I hasten to add that I’m no martyr: if I were feeling pain, I’d have had DH set a new land speed record to pick up that script. And though I personally didn’t need them, I heartily support the idea of offering narcotic pain relief for women who do need it in those circumstances, and of having it as the standard for pain relief for CS moms.
Should you get pregnant again, I hope that you have an OB as wonderful as mine!
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I listened to the audio interview. What Shah seems to be promoting is a model very much like the Australian one (initially based on the British system) where public hospital births are mostly midwife-attended, with medical on-site back-up as needed. Private hospital births are OB attended with MW assistance.
Midwives in Aus are nurse specialists, not nurse practitioners, so they perform both traditional ‘nursing’ roles and extended care roles in delivery, including using drugs and both cutting (where indicated) and repairing episiotomies.
It is notable in Aus that the Cesarean rate is significantly higher in the private hospitals. This is a combination of several things: the presence of OBs, older women and maternal choice.
This seems to make for a good balance, though there is more limited access to epidural for public hospital patients. All Public patients are treated within the universal Medicare system, so there is no financial outlay (not means-tested).
The NHS is known for cost containment through limitation of choice, though overall good quality and outcomes.
The way our health systems run tends to represent some aspects of the prevailing national character and what the population generally prioritises – cost vs choice, for example. Aus finds itself somewhere between the UK and the US.
it would be interesting for Shah to work in the UK to see whether the system he admires has limitations he didn’t know about. He mentioned the increased risk for first-timers at home (as in the UK Birthplace Study) but did not mention that as a recommendation.
In Ontario there are a couple of publicly funded birth center pilot projects being touted as “cost effective” alternatives to hospital births while failing to highlight the fact that they are not as safe and can only offer limited pain relief options. It seems like an attempt to cut corners on women’s health.
Prostatectomies are often done under spinal anesthetic. These can lower blood pressure, which can make things worse if the person bleeds. Maybe a whiff of nitrous would be better? The procedure last much less time than most labors.
(Sarcasm font: wouldn’t wish this on anyone).
He makes the valid point that obstetricians are much more likely than midwives to pick up their scapels and use them. Huh? These statements drive me absolutely crazy. Believe me, if midwives could pick up their scalpels and use them, they would. Midwives are into vilification of tools they cannot offer. In our hospital, it used to be that midwives had to ask the obstetrician before they could get an epidural and the conversation happened between the ob and the anesthetist. Then, we changed the rules so that in certain circumstances (progressive labour) midwives could order them directly. Suddenly, the incidence of epidural use in the midwifery clientele basically doubled. (Add in the fact that once the patient receives the epidural, the midwives transfer care to the labor and delivery nurses and they go off to bed!) well well well…
The hypocrisy makes me crazy.
Well, here in Latvia midwives can perform many interventions and also provide epidurals… yet most of them still insist on foregoing it (as if high cost already didn’t decrease amount of women who can afford epidural). I just attended birthing class, and midwife seemed competent and reasonable in the beginning (she explained that any interventions are used if necessary) but the further she went, the more midwifery myths came out, and the kicker was proud story of tricking laboring woman who requested epidural to not get it in time…yuck! Seems that only option to avoid such situation is to put my husband on tracks and ensure that he’ll advocate for me if I’ll feel the need to have pain relief.
FWIW, our midwifes are more like CNMs, working in hospitals where OBs are available too, but standard model of care is that midwifes are PCPs during labor and OBs are called in only in case of serious emergencies and to perform C-sections. In general labor in hospital is for free, but epidurals have to be paid out of pocket – only in very few cases midwife or OB can deem them medically necessary and then the cost is covered by government.
Does the same burden of proof that pain relief is “necessary” fall on men having procedures done? That’s horrible. Isn’t ‘patient was in pain and requested relief’ significant enough for it to be necessary?
That’s the point – pain relief during other medical procedures is included in total costs and never charged separately (anesthesia during gastroenteroscopy is one of exceptions, though with enough waiting in queue you can get this as a government subsidized procedure too). Epidural is given for free when it turns out to be only option to actually facilitate labor, also in some cases with extremely painful back labor etc. But it’s not widely advertised by hospital that they give it for free in such cases, and evaluation of whether it’s “medically necessary” lies on midwife/OB and apparently is quite subjective.
In Aus, if you’re a private patient, your anaesthetic costs are always billed separately. But of course you’d never go without anaesthetic during surgery.
Hello from 35 weeks, and fresh off denting a hole in my wall with the copy of “Birth from Within” my hippie friend lent me. The agenda drips off every page. I just don’t get why they keep making a virtue of avoiding pain relief? I’ll tell you, the only time I wanted to “move around” during labor was when I was writing in pain. The epidural cured that. (Of course, I labored from about midnight to 6 am, which doesn’t tend to be prime moving around hours, anyway…)
I wanted to move alright. To the anaesthetist.
*high five*
When I was first in labor, I wanted to move around a lot. I think I was trying through some misplaced instinct to run away from the pain. It didn’t work. The epidural and nap was a much better solution. Actually, when I woke up, I did move around a fair amount. It was a good epidural.
I’ve never felt a benefit from or desire to move around in labor. I wanted to get to the hospital, get in bed, lay down, and stay there. I might want to roll over now and again, but that’s it. And I had unmedicated labors, so I could have been walking or dancing or whatever. There was just no appeal in anything other than a nice lay down.
I haven’t given birth but I have passed kidney stones.
I was screaming despite being on Loratab 15s and didn’t want to move except to curl up on the floor and maybe die.
After that experience all few and fleeting thoughts of ever having an unmedicated birth flew right out the window. There’s no prize in life for being a pain martyr and we should stop encouraging women to just bear pain gracefully.
How many women have chronic pain that goes untreated because of our culture romanticing the graceful, uncomplaining woman in pain who sacrifices so much and suffers in dignified silence? *eye roll*
Some subcultures romanticize both stoicism in both genders.
Yeah we’re trying to train Dad out of that. Especially after he nearly died from appendicitis and THEN nearly lost a kidney for not looking “in pain enough” according to ER triage. That split ureter by a kidney stone that was took big happen to my dad. Lucky for him his kidney didn’t die.
There’s no medals for either gender for suffering correctable pain, that’s for sure.
Not that I’m saying you should be a blubbering mess on the floor but you don’t have to sit and pretend nothing is wrong either. Extremes are a very bad thing.
A friend’s father (old school Polish descent in the US) actually had his teeth pulled without anesthetic, for dentures back in the 1970s. He had to shop around for a dentist willing to do this (he even refused the novocaine!). The dentist was reportedly shaking by the end of the session, and refused to see my friend’s father for any further dental work once the dentures were in place. My friend’s father used to boast of this story.
The only reason I wanted to move around during labor was so I could use the bathroom as needed. Often at 8 1/2 to nine months pregnant a bedpan is uncomfortable and almost unusable. By the time you get a nurse in your room and get unhooked from everything, it can be too late for the bedpan.
But I wonder about these people who want to move around the whole time. I was in too much pain for that. But according to crunchies moving around will prevent all that pain.
I desperately wanted to move around. Maybe not go for walks, but at least sit up and roll over at will. But, due to two external monitors, IV antibiotics, magnesium, pitocin, and who remembers what else being hooked up to me, I could not even lie on my side. It was awful. Probably still would have wanted an epidural, but would at least have felt less like I was literally tied to the bed.
IV antibiotics AND magnesium? Worth being tied to the bed for a few hours to avoid the long-term complications of infection and PIH, no?
It doesn’t sound like she’s regretting the abx and mag. Our brains can be aware of the reasons why we’re undergoing pain and/or discomfort without our bodies wanting to cooperate! During my son’s birth when I needed to have my body held still while I was telling the staff that I understood why they needed to hurt me and to please do what they needed to do. It’s crazy.
I had almost all of the same stuff going on, and I was still able to lie on my side? I also had a catheter and an epidural. The only thing I didn’t also have, was the antibiotics. It wasn’t totally easy to roll on my side, but it was doable, and I switched from side to side during my labor. And used the bed to help me sit up.
Not that I loved being stuck in bed. I didn’t. But I wasn’t frozen in place, even with all that stuff hooked up to me.
Slightly OT, but are eating disorders another example of women’s pain not being taken seriously? They are the most lethal mental health condition, and usually happen to (young) women. It wasn’t until recently that they reduced the importance of current body mass in making a diagnosis- as in, you had to already be thin to a dangerous extreme to meet criteria to get your illness taken seriously. I can imagine how excruciating and isolating it must be to be plagued by obsessive thoughts over food choices and body image. Aren’t mental illnesses generally diagnosed and treated when they are mentally/emotionally distressing and disruptive to quality of life, not when they are so bad that the physical evidence is irrefutable?
Yes, this change in diagnostic criteria for eating disorders has been a good one. Especially because people with a genetically bigger body frames can be seriously starving at weights that are still in the normal BMI range. I admitted a man to the hospital the other day whose regular doctor had told him that a BMI of 20 was still normal and that his weight loss was healthy (he had started the whole process with a muscular and mildly obese build). He was in a junctional rhythm, and labs showed pancytopenia (bone marrow suppression) and a starvational hepatitis among other abnormalities.
I just watched the movie “Hunger”, which stars Michael Fassbender as Bobby Sands and depicts the 1981 Irish Hunger Strike at Maze Prison.
Parts of it were very difficult to watch. He looked like an Auschwitz victim.
When Hugh Jackman played Jean Valjean in the 2012 “Les Miserables” musical movie, he deliberately went without water for three days while filming the beginning scenes where Valjean is released on parole.
I wonder if Fassbender did something similar for the Bobby Sands role. It was truly disturbing to watch his physical decline. Running sores, loss of all body fat, the works.
That’s pretty scary. I lost a lot of weight, and at the lowest point, I was also getting conflicting messages. Doctors are quick to say “great!” because the more typical outcome is that people stay obese. My shrink, too, was very positive about weight loss, even though I had already gotten down to a “healthy” BMI. On one hand, I had all the social encouragement to keep losing, but I was probably not eating enough and was losing more muscle at that point. I’m glad I listened to the friend who said something like “hey it’s great you lost weight, but you did it to be healthier, and going any further will not achieve that.” I wouldn’t call my eating at the time “disordered,” just misinformed.
I also knew somebody who had disordered eating (quite obvious to anybody who ever saw her at a meal), but she had a normal body size because she was getting so many calories from alcohol. Very dangerous, but the disordered eating part of the equation was never addressed.
Re that last: oh yeah. I grew up with a mother who ate virtually nothing: like, she’d skip breakfast, eat a potato for lunch, and nibble a little for dinner. She was always slim, and held being thin as a moral prerogative. (Like, when I briefly tried anorexic eating, she encouraged me wholeheartedly because then I’d finally “look good.”) She also drank like a fish; it’s where she got all her calories. But, you see, that was okay, because she didn’t gain much weight that way. *twitch*
You could be my sister. Even when my mom was in an inpatient treatment program for mental health, they focused on the substance abuse (and depression/anxiety) and did not even touch the eating disorder because her BMI was in the “normal” range. Admittedly, there is kind of a chicken and egg conundrum with alcohol dependence and disordered eating, and I guess they had a limited time frame to work with (and needed her cooperation). But seriously, she had so many classically bizarre behaviors around food to limit how much she was eating and had been to the emergency room for “dehydration and vitamin deficiency” (eating way too little and drinking way too much). The eating problems didn’t go away when she got (briefly) sober, either.
I think one of the issues with eating disorders is that patients frequently don’t seek treatment. And unless they have severe anorexia–where their appearance may prompt questions from family and medical providers–they often fly under the radar. Some patients (not all) may even like what they are doing and not feel that they require treatment. I can count on one hand the number of times a patient has volunteered information about an eating disorder. It’s almost always discovered in the course of treating depression or anxiety and that is what the patient wants to focus on. It’s very sad.
I’ve discussed the health consequences until I’m blue in the face, to no avail. Sometimes patients need to hear the same message multiple times before it starts to sink in, but I think there is a feeling of helplessness among clinicians since these patients are often so resistant to wanting treatment. And we live in a society that sends the message that one should be thin to be popular, beautiful,…etc., while at the same time promoting easy-to-prepare foods that are less than nutritious.
“these patients are often so resistant to wanting treatment.”
Anorexia is an egosyntonic disorder. Not wanting treatment is part of the brain abnormality. It makes it very difficult to help.
True dat. The ‘treatment’ for the physical symptoms of anorexia is relatively straightforward. It’s getting you to the point where you can actually do it that’s the tricky bit.
It’s a fucking trip, I tell you, to look in the mirror at 75lb and honestly, legitimately, feel fat.
Yeah, I was thinking more about the problems of the (old) diagnostic criteria, not so much the clinicians working with patients. I have no doubt that it’s frustrating. On the other hand, I have heard of people seeking help (in- or outpatient programs) before they were at a BMI low enough who were denied coverage because they were not physically ill enough. Also some people in recovery (in retrospect) think they may have recognized the problem earlier if they hadn’t been able to dismiss it because they were not (yet) dangerously thin and still had a period. I don’t know (I’m not a clinician), but it just seems unhelpful to me in any case to use tragic, end-stage disease indicators as the criteria for a mental illness.
“Also some people in recovery (in retrospect) think they may have recognized the problem earlier if they hadn’t been able to dismiss it because they were not (yet) dangerously thin and still had a period. ”
Yes. The locked in thinking can often be seen long before the person is dangerously thin. It makes my job a lot more straightforward to be able to say to a patient and/or their parents “this is early anorexia” rather than “be careful with this weight loss or within a few weeks to months you might meet criteria for anorexia”.
Why stop at birth? Imagine how much money could be saved by withholding pain relief for trivial medical procedures like vasectomies.
Imagine how much money we could save removing teeth the old-fashioned way!
When children have “spasms” like my uncle did in the late 40s, we can just rub their feet with garlic. Make sure it is organic. Hey, that’s what he got…
People have been having limbs sawn off without anaesthetic for hundreds, even thousands of years. Its clearly how nature intended amputations to be.
Except for maybe a BIG slug of alcohol – oral anaesthetic.
The one that makes even more sense is colonoscopies. We have actual scientific studies that show that if the colonoscopy process is started without anesthesia or sedation, and people receive adequate encouragement during the process, that up to 50% of people can get through the colonoscopy without relief. And that among those who do, some even choose to have their subsequent colonoscopies “naturally” to avoid the hassle of having to get someone to drive them home.
Why aren’t we requiring everyone to at least give it a try without meds? The average healthy person has 3 colonoscopies in their life. Think of the savings. Dr. Shah could write some articles with a scolding tone to publicize this waste of money. We could encourage the geriatric crowd to apply pressure to their peers: “Did you get through it naturally, or did you cave and ask for meds to numb you out?”
I actually asked my gastroenterologist if I could do the colonoscopy without anesthesia because I’m kind of neurotic about anesthesia. She flat out told me no. This may have to do with her desire to not listen to me say “hey, is that a polyp? look over there! are you sure that’s ok?” the whole way through.
Ha, a doctor friend of mine was doped to the gills during his colonoscopy and did a running commentary on the procedure. Apparently it was very entertaining. “WOW look at the size of that polyp! WOOOO you got it!!”
I never, ever want to have a colonoscopy. If I was told I had to try without pain relief, I wouldn’t go.
Have you all seen this?
http://www.theguardian.com/commentisfree/2015/may/29/obsession-natural-birth-judge-women-pregnant-medical
The author makes similar points as Dr. Amy about how “natural childbirth” denies women choice.
And funny too!
I love what she says about “women being berated for opting for a birth plan that involves anything more sophisticated than giving birth in a woodland attended to only by twinkly-eyed foxes.”
Or dolphin midwives.
Please tell me you guys have seen that episode of Penn and Teller’s Bullshit.
I can’t watch Bullshit anymore. I watched one on a subject that I disagree with them on, and from that perspective found it very light on facts and very heavy on denigrating anyone who disagreed with them. I found myself wondering how an episode would appear to anyone disagreeing with them on a position I agreed with, and had to admit it would be very offputting and not convincing at all to such a hypothetical disagree-er.
Yeah I can definitely see that as being an issue. I mostly watch for the entertainment factor because I know it’s been hyperbolized. I laugh at myself quite often so even when they’re making fun of something religious I mostly just laugh anyways as a “Well when you put it that way it does sound pretty funny.”
But for facts, you’re right that it’s incomplete and relies on insult based humor that would be off putting to a good number of people on the other side of the issue. Not everyone is going to laugh off someone insulting their core values. I can only do it because I’ve been insulted and attacked for my core values most of my life.
I haven’t! Link?
You’ll need a Hulu account but the whole episode is here: http://www.hulu.com/watch/610324
Lovely article.
I read this part:
“(Unmedicated childborth has) shifted from being an option feminists promoted in the 1960s to help free women from the male-dominated atmosphere of hospitals, to being yet another stick with which to accuse women of being insufficiently self-sacrificing as mothers.”
and thought, ironically, that the real impact of feminism has been the huge rise in women specialising in obstetrics in recent decades, so the hospital environment is no longer ‘male dominiated’.
Having read the article to which you are responding, I am not sure how you got the idea that it is suggesting homebirths are great because they save money. It does not say that at all.
There are situations where interventions are required. There are also many where they are not. Especially in locations where having a hospital birth entails travelling away from home weeks before the due date, in order to be near a hospital when the time comes, it makes much more sense to have trained midwives to care for women prenatally to ensure that women don’t travel away from their homes and support systems unnecessarily, and give birth close to home where possible.
Certainly in the U.S. there are major issues around midwives who do not have proper training (and tout this as a good thing) and fear of *any* intervention. That is not good.
But many women can safely give birth in their communities, and avoiding unnecessary interventions can have many benefits beyond “saving money.”
You know, we found out that I was going to have a PPH hemmorhage requiring blood transfusion… riiiiiight after my baby popped out and I started bleeding everywhere. No time to be “transferred”. Plenty of time to bleed to death without multiple doctors and nurses looking out for me.
This sort of thing is always a risk, no matter how qualified a homebirth provider might be. It’s just the truth. You can find out at the very last second that you have a complication that can kill you or your child. You can find that out without access to any real medical help, or any real medical providers – let alone the several providers that are often truly needed in these situations. You find out how “safe” your birth was, after it was over. When you can view it with the safety of hindsight.
I’m sympathetic to a few of your points here – especially the points
about underserved communities with little access to medical care. But using “interventions” like it’s a dirty word (or always a regrettable outcome) doesn’t help anyone’s credibility.
And the issues with US midwives aren’t just “major”. They’re pretty much catastrophically bad. Let’s not be coy about that.
Yup. I had a “textbook” unmedicated labor and delivery, right up until I delivered the placenta and started hemorrhaging. I had a cervical laceration that required surgical repair in the O.R. Even with extremely prompt diagnosis and care, I barely avoided a blood transfusion (had my hematocrit dropped one more point, I would have been given blood). I would have died during transfer if I had given birth at home.
Let’s not forget that midwives will not always go to the closest hospital as what happened where I live with the Vicki Sorensen case.
I know where her birth center is. That time of night, if you’re lucky, it’d take about ten minutes to get to Valley View Medical Center if you didn’t go by ambulance. Maybe five minutes by ambulance if they really high tailed it and Southern Utah drivers weren’t being the asshat drivers they are and actually pulled off to the side.
However she didn’t want to go to Valley View because “They don’t love us there.” She wanted this mother and her twins in distress to go to Dixie Regional in St. George. Fifty miles away. It’s a forty five minute drive on a good traffic day without construction. That stretch of freeway has been under construction for the last two years and isn’t close to being done yet.
So instead of opting for Valley View, which has Lifeflight to Dixie Regional if needed, she wanted to go forty five minutes away because she didn’t want to deal with the OBs here yelling at her for putting a mother in danger. Again. The OBs I’ve seen cry when a baby comes in from a botched home birth that isn’t going to make it. Or when a fellow doctor lost her baby and every OB, pediatrician, and Emergency physician in the area spent hours after their shifts were supposed to end trying to save him when things went down hill and cried with and held her after Lifeflight took off. Those monsters.
I absolutely do not trust someone like that to get me to a hospital if I had an abruption. With this midwife both my baby and I would be dead before we even got halfway to the “nice” hospital.
No matter how skilled your providers are, they can’t do much for massive PPH at home.
My cousin had a placenta abruption during labor in the hospital that nearly killed her and the baby as it was. If she had been at home, they would most certainly be dead. And by the way, she had a perfect low-risk pregnancy, so there was absolutely no indication that it would happen.
If a woman lives so remotely that she would have to travel for hours to get to a hospital, how is midwife care going to benefit the situation? The midwife would likely have to travel quite a distance to get to her home, and the population would be so small that a real midwife could not keep her skills up (or make a living). And then if there is a problem that requires transfer during the labor, she has delayed travel to safety for that many hours.
I think the idea is that if someone is going to travel when the woman is in labour, better for it to be the care provider than the woman. There’s always going to be an elevated risk to being so very far from a hospital, though.
“I think the idea is that if someone is going to travel when the woman is in labour, better for it to be the care provider than the woman. ”
It may be more comfortable for the care provider, but it is not better. Delay between labor onset and access to the midwife exists in either case, and if the midwife arrives and subsequently finds a problem, the mother is no closer to the help she needs.
You’re right! Women’s pain is fucking irrelevant!
>:-(
Giving birth naturally in a backwater with a midwife, instead of safely in a city hospital, may make sense to you but it doesn’t to me. I’ll make up my own mind about where to give birth!
And I’ll choose the safest setting, whether I’ve been labeled low risk or not. I know that a low risk pregnancy can end in a high risk delivery.
I’d also choose an epidural, though it’s not “required”. You have no right to withhold from me the interventions you consider unnecessary.
That is the problem with schemes such as Dr. Shah’s. They presume to make decisions for women that women should be making for themselves. And they place ideology ahead of safety.
I think the logic is that a few lonely weeks away from home are less of a bummer than having your baby die in your living room. Or having your baby die anywhere. Moving people to resources makes sense, because some resources (like operating theatres and blood banks) aren’t portable and can’t be made so.
If you’re concerned about isolating women from their support systems, make it possible for them to bring a few people along with them when they go to stay near the hospital. And honestly, technology has eased this issue a great deal. I spent a week largely alone in hospital in the lead-up to my daughter’s birth, but was active on-line and received a lot of emotional support from friends and family that way.
Dr. Shah is the founder and executive director of Costs of Care, a non-profit dedicated to eliminating unnecessary costs in medical care. When doctors discuss treatment intensivity, they are usually concerned about two things: cost and the point at which the risks outweigh the benefits.
This brings up a bizarrely personal issue for me: I’m thinking of quitting clinical medicine and going to work for pharma in outcomes research, including examining questions like, “Is drug X cost effective?” and “How do we make our drug look appeaing?” My 10 years ago self would have told current self “oh, considering going over to the dark side, are you?”, but my current self is not so sure: There’s so much pressure for “cost containment” and limiting care, that I think a little push back is justified. (Though I’ll still only work for a company that can handle the answer, “No, this drug has no benefit over the competitor in terms of efficacy and is more expensive. Cut the cost, find a new indication, or junk it.” Pushing back against unreasonable cost containment is one thing, pimping useless drugs is quite another.)
And there’s absolutely no reason that safety needs to be sacrificed for cost effectiveness. I work for a not for profit hospital chain that manages to have lower cost that most of the US without sacrificing quality.
A lot of it has to do with the early adoption of an Electronic Medical Record System which has been used at Intermountain since I think 1988 and they use it to track patient outcomes and doctor’s practices. They throw out the protocols that do not benefit the patient in a meaningful way and keep protocols that do. They can track that very quickly with how their database is set up.
Really one of the best things about the system is that I live in Southern Utah but if visiting SLC and get in a car accident, if I’m brought to an Intermountain facility they already have my records in their shared database. So they’re already aware of my blood type (they still cross match just to be sure), medication history, pre-existing conditions, anything that’s ever been done at Intermountain. They’d even know to check and make sure I don’t have liver lacerations that are bleeding out almost immediately because my file has information about a particular type of benign tumor that affects my liver that can cause severe bleeding in even a lower impact situation.
I think that’s how you save money. Smart usage of an EMR system that can be analysed to see if the latest, greatest, but terrible expensive procedure is worth the cost to the patients. If it isn’t don’t use it and don’t put that financial burden on the patient.
That system sounds really awesome. Can you imagine if we could somehow get every hospital in the country on the same system like that?
Instead, every health system that uses EMRs uses a *different kind of* EMRs, and the systems can’t talk to one another. Headache city.
Ugh they do… And it’s really kind of dumb. If they all used the same database management system then they could throw any Customer Service Portal software over it for ease of use by the employees. As long as it puts data in the same way as everyone else we’d see a huge improvement and could share information.
But then you have people screaming about invasion of privacy. Funny thing is even the conspiracy theorists worried about secret microchips in Utah like the interconnected Healthcare systems.
You silly person…if everyone is *forced* to use the same system, that’s communism, which is like, the worst thing in the world. Free people in a free country need to be free to choose whatever data storage/customer service/phone tree service they want…even if their choice is completely asinine and creates headaches for everyone involved. It’s freedom. /sarc
They don’t have to know. If you change the interface to it for each hospital chain they’d never know it’s all the same under the hood.
We could NSA them!
Not to sound completely biased but I think if the entire country implemented the Intermountain Healthcare model we’d see huge improvements in our health care. It wouldn’t fix all the problems but it’d be a big step in the right direction.
One of the really nice things is that Intermountain is not for profit with an all volunteer board of directors. When the big wigs can’t squirrel away all the money, the money goes back into the hospitals and the community.
The hospital I work in is in a very rural area and the building is about twelve years old. However the entire ER and ER registration area is being completely redone based on employee and patient feedback along with the phlebotomy rooms. Registration was actually asked for their input on what they want in the redesign since we’re the ones who man that area.
Besides improving facilities Intermountain also has several free health fairs for the communities their hospitals serve that include free blood pressure, blood sugar, cholesterol,
It is argued that good quality care saves money: Anticipate issues, do it right the first time, avoid crashes. That’s what “initerventions” are for. Complicatiions are expensive – not to mention undesirable.
“Unnecessary interventions” = pain relief. Of course it’s unnecessary, for values of unnecessary that include “not vital to survival.” But why is it virtuous or desirable? Why is it something that should be encouraged to be avoided?
You’re right that the article does not discuss costs, but that’s the subtext because the author, Dr. Neel Shah, is heavily involved in health care cost containment policy. Plus, one of the big rationales in the UK for homebirth is financial.
Which interventions are really “unnecessary” WHEN THEY ARE DONE?
Oh, after the fact it’s easy to see that, no, we did not need to run a heplock for an IV. However, can you say that before you start?
It’s the same old “unnecessary c-section” crap. Which c-sections are unnecessary? We know that a large number of them (maybe 95% of them, in the case of breech presentation) are not required to deliver the baby successfully, but we don’t know which 95%, and nobody in their right mind is willing to take that 5% risk.
Similarly other interventions. Even though we know many births could occur without them, since we don’t know which ones will and won’t, we take precautions with things that may turn out to be unnecessary. If we knew that ahead of time, we wouldn’t do it. Unfortunately, we don’t know, so we want to be safe.
This is why Dr. Shah’s article frustrated me. He says “do less” but he won’t give specifics. Come on buddy, tell us exactly which of the routine cares are unneeded and should be stopped. And on top of that, do it yourself and show us how well it works.
If you want to “do less” the proper approach is to do the research to help to try to identify those situations where it is not necessary and those where it is necessary. If you can show that women with characteristics X, Y and Z will not need a heplock, then you have made a real contribution to improving care. Of if you can show that women with W, V and U don’t need a c-section even though they have T, then that is a great way to cut the c-section rate.
Intermountain has actually already done a similar thing to reduce things like readmission after a cardiovascular event and reduce death rates from ARDS.
This is why proper use of an Electronic Medical Records system will be what really makes the difference, in my opinion. Sure a lot of hospitals have them but they’re not utilizing them in a way that can improve patient care.
This article outlines it better than I can: http://mobile.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?pagewanted=all&referrer=
Where, oh where, is any member of the anti-C-section brigade who is clamoring for term inductions for everyone?
I still poke fun at my mom for trying to do my 14 hour labor drug-free (she had an epidural at the end, when she should have from the start!).
I still haven’t forgotten the agony of my second labor. It was a precipitous labor, so very quick, no time even to get an IV in (needless to say, no time for an epidural) and those twenty minutes of hellish agony left me with PTSD and probably contributed to my PPD. I’m over it enough to try for another baby, but I’ve not forgotten. I’m trying to figure out how to avoid a repeat. Like maybe an elective 39 week induction with the epi already in place or something like that.
A 39 wk induction was exactly what my OB suggested, after
I experienced the same thing. I had a lovely 2nd birth!
I went at 38 weeks with my first and barely made it to 39 weeks with my second. I really want an induction but I might not make it. I just hope my water does not break this time around and I have more time.
Protip: If *Queen Victoria* thinks you have a backwards view of things, maybe reconsider.
It’s not just for birth, it’s all female medical care. I was taking a medication that caused a mild stroke. I was in my mid-20s at the time. Even though the right half of my face was drooping and I could not move my right leg and arm, the ER said that I was simply having a “panic attack” from a hard day at work. Um no – work was very easy and I had been relaxing on my lunch break with a good book when the attack happened.
Saw my primary doctor the next day and he was pissed at the way the ER had treated me. Got me an immediate MRI, MRA and CAt-SCAN rushed through my insurance, but by that point it had been about 24 hours since the incident. While they found nothing I now have neurological issues where I have poor memory, weakness in my right hand and will drop things, and irritability.
I’ve gone to other ERs when my symptoms get really bad and I have been written off as a hypochondriac. I don’t want meds, I want answers and treatment. But my husband has a small fall where he *might* have hit his head (no witnesses to it, but a possibility and I am paranoid when it comes to head injuries), he got the whole enchilada – scans for injuries, blood tests to see if there was a medical reason he fell, etc.
It depends on the complaint, but for the most part I agree. Now, when I had a bladder infection they treated me like it was the worst, most dangerous thing in the word. When I had pneumonia they told me I coughed myself into a panic attack.
Now, granted the circumstances were strange. I have an autoimmune disorder that causes a mild Grave’s like thyroid syndrome. I was having no symptoms of hyperthyroid but my thyroid swelled into my esophagus and caused me to have trouble clearing mucus out of my throat. So, I had a mild cold that was causing a lot of post nasal drip and had been having trouble choking on it. Then I woke in the middle of the night coughing and couldn’t clear the mucus until I vomited. When I went to the hospital I had 100% oxygen saturation in my peripheral capillaries and no abnormal lung sounds. An X-ray showed the very beginnings of pneumonia. The doctor said it was probably the earliest he had ever caught pneumonia. Still, why tell me before the X-ray that I had a panic attack and give me Xanax? Would they have treated a man differently?
I’m not sure – one of my male friends kept going into A&E because his chest felt tight, he felt dizzy, and his heart felt funny. They kept telling him that it was anxiety/PTSD and wouldn’t listen when he tried to explain that no, it was different to those. Eventually, he sat down and refused to move unless they checked out his heart properly. Lo and behold, he was swinging back and forth from tachycardia to bradycardia while perfectly calm. Still not sure what’s going on because his appointments keep being rescheduled at the last minute.
From the ED persepctive, over decades, I can confirm that this was not a simple diagnosis to make, in either gender. For that reason, many tests and inteventions end up being done, that are later seen to be unwarranted. We tend to err on the side of over-diagnosis, which also has its harms.
Word. I lost a grandmother to the attitude that women’s health concerns are all in their heads.
As did I. Pancreatic Cancer that was written off as arthritis.
I wish I had read this argument for pain relief before I went into labor. I did have an epidural, but I was “trying” for an unmedicated birth, which kept me from sleeping through the early stages of labor, so by the time by babies were born via c-section, I was so out of it I couldn’t think to make requests for things I wanted (such as being able to see the lift out of me).
It’s pretty minor stuff – I’m not claiming birth trauma or anything. But if I had thought if it as unnecessary suffering instead of somehow the better way to give birth, I would have gotten pain relief sooner, gotten more sleep, etc. I was scared of not being able to walk, of causing a c-section, and I don’t even know what else.
These are the truths we hold as self evident…laboring at home means mom will be mobile. She will be able to take great big cleansing breathes and therefor giving oxygen to the baby. Her labor will progress naturally without the discomforts of IV’s, hospital gowns, loss of privacy, enforced fasting which have all been proven to slow labor down. Routine epidurals mean mother can no longer walk around, empty her bladder/bowels, eat/drink. Epidurals slow down labor and increase the risk of post partum fever( causing mother and newborn to be kept apart). The longer a mother labors at home the less opportunity for the hospitals to interfere with cascade of interventions. Infact it is better for mother to not have pain relief because really bad intolerable pain means something is wrong and the ob/midwife needs to be more proactive. If the pain is numbed important feedback information is missed….I got a whole file cabinet filled with years of this crap folks….
That crap cracks me up. I was not progressing as I hurt so freaking much. I was stuck at 4 and nothing was happening. Was finally able to get an epidural and went from 4 to 10 in 30 minutes, no joke. I was finally able to relax. Then the baby popped out after two pushes, no tear or anything. Smooth sailing that would have never happened at home or at the hospital without an epidural. I would have had to have a C-Section.
I was induced at 37 weeks for medical reasons, and after a night of cervadil and then five hours of pitocin, I did not budge from 2 cm. Not to mention the excruciating pain. After I got the epidural, I actually dilated! It was glorious. Ten hours after getting the epidural and after 15 minutes of pushing (heck yeah!) my daughter was born. I’m probably going to have to be induced again, and I want that epidural again.
I spent 4 days at home in early pre-labor stages before being admitted.i held off on the epidural and felt the contractions. They did NOT get worse as my baby’s heartrate was dropping. If it wasn’t for the monitors I would not have known something was wrong. Smartly, I did get an epidural which I should have done sooner right before we needed an emergency C. The epidural did not cause the cord entanglement. The epidural eased my pain and allowed my surgery to start when it needed to
I was progressing just fine and the pain was intolerable. I have a low pain tolerance. It’s how I’m built. After my epidural, I was able to stop writing on the bed and let them do cervical checks and you know, explain to me how to push. And actually concentrate on pushing. And enjoy the birth of my child. And I totally did not forget the pain later. I remember it VERY well. And I had no side effects from my pain relief. Pain relief rocks.
As always, Dr. Tuteur, you make me think. And the more I think about this guy, the more puzzled I am. How does a guy with this attitude get traction enough to have a platform? And he’s an attending at Deaconess?
The source of my puzzlement is that we are in the midst of a “safety culture” moment in hospitals. Everything is being aligned with checklists and more checklists, checks and re-checks. Protocols are in place for every emergency and drills are performed regularly so that even rare events will be dealt with smoothly and effectively. This is as it should be (although I must say, that I do roll my eyes that we do a time-out in the c/s room to say, “This is Mrs. W and she’s having a c/s,” because that’s all we do in the c/s room….but I digress….)
But in the midst of this moment, this guy basically says: “Safety….unless you’re having a baby or are being born,” and I my response is: “You will NEVER care for me or for ANYONE I love. I will make damn sure of that.”
I do make the following prediction with confidence: he is going to have ONE BAD OUTCOME and he WILL be sued and it WILL change his tune. Because, can you imagine the hilarity in court when someone brings up the tweet comparing a c/s to an exploding airbag? That alone will add a couple of zeros to the judgement.
There is no excuse for giving mothers and babies substandard care. None. And if he wants to be a bean counter, he needs to count ALL the beans that come into play, including malpractice judgements and PTSD and lifetime care for injured children.
I think it’s the same as what’s happening with schools. For public schools, the protocols for testing and for evaluation of teachers have gotten stricter over the past few decades, by popular demand. At the same time, barely-regulated charter schools and homeschooling have become hip and trendy
Similarly, the safer hospitals become and the more routine and safe hospital birth becomes, the greater the number of women who want to do stunt births. I don’t understand why, but it seems to be the same sort of people competing to do ever more extreme versions of both.
I figure that in a developed country where you have every modern convenience and very little worry you have to set yourself apart somehow. How can you be special and above the rabble without some stunts to cause more drama.
Hear, hear!
And I have to say that I appreciated the time-out they did at my C-section. Sure, I knew my doc, and he wasn’t going to screw up, but it was still good to know that they’d double-check that they’re all on the same page.
Wait, this jackass is at Beth Israel?
Beth Israel, where the c/s rate is high because they have such good high-risk facilities? Beth Israel in the same Boston that has Nancy Wainer Smith practicing midwifery in it? THAT Beth Israel?
What on earth are the staff doing that they haven’t pounded better sense into that young man?
My thoughts exactly. How did this charlatan get into Harvard and why on Earth is he still there? And why are serious media queuing to interview him?
Seriously? Two reasons: First, he’s a man. I’m sorry, but that does matter. But second, and probably more important, he’s saying things that the powers that be want to hear. Rich people don’t want their “hard earned” money going to help people who don’t “deserve” help. And no one deserves help, in their world view. So they are ready to hear anyone talk as long as he (and I do mean HE) says that costs should be cut.
I find it revealing that he won’t get specific. He says that OBs in the US ought to practice more like midwives to save money. Ok, Dr. Shah, tell us exactly how.
Are you saying we should strictly limit inductions?
Are you saying we should stop screening for GBS?
Stop routine screening for gestational diabetes?
Less frequent prenatal visits?
Fewer labs?
No heplock unless “indicated”?
Hand held dopplers instead of strips?
Policies limiting epidurals?
A policy of no MRCS?
What exactly? Tell us. And even better, implement it in your own practice and then show us the results.
I just perused quite a few case reports of medmal suits in Contemporary OB-GYN, and almost all of them were cases in which vacuum extraction was done instead of c/s. 4th deg lacs, shoulder dystocias. They were mostly defense verdicts, but the cost of the multiple surgeries and then the costs of the lawsuits to the hospital system and insurance companies… Very very expensive. Plus the fistulas and brachial plexus outcomes :/ this guy is so blasé about avoiding c/s!
Yep – legal cases resulting from harm almost always allege failure to act (or to act soon enough) – not excessive intervention.
If one were to look at this rationally, based on outcome stats, the resulting guideline might suggest an INCREASE in c/section. THEN what would he say?
My husband and I are trying to conceive our second baby, and I already know what my birth plan is going to say: Epidural upon admission. I was induced with my son and expect I will be the second time around. The first time, I waited until I was 4cm, and the pain was horrendous. The epidural wasn’t placed properly the first time and had to be re-done, and during that wait I was having long, hard, and excruciating contractions. It was horrible and exhausting.
My best friend had a fast and painful labor with her first son, and when she was induced with her second she opted to have the epidural placed before the pitocin was started. She said she felt one contraction and it was awesome. Sign me up!
I was induced with my first two kids because they were really overdue, not to mention huge. Like you, I waited until the pain was excruciating to have an epidural with the first. I was shaking so much, it was hard to place. With the second, I didn’t get it right upon admission, but I did choose to have it much earlier (before manually breaking my waters after a day on the pitocin and bearable contractions). It made a huge difference in pain relief. Unfortunately, I should have had a c-section and didn’t, mostly because I viewed a c-seciton as inferior and my midwives talked the on call doctor out of it, letting me try a big longer for the supposedly better vaginal birth. This was a bad choice (I had a c-section with my third and the recovery was actually easier than with the first two). Pain relief is absolutely a women’s rights issue.
I had to wait until 4 myself, because there had been a three car collision and had taken the victims to the ER next to my maternity ward and the anesthesiologist at the ward had to go over there and help because they had all the ORs in theatre. BAD day to go into labor…
BAD hospital for not having enough anesthesiologists on duty, for not calling more in, and for making the pain of laboring women last priority.You deserved better.
Well…You have to be somewhat realistic. You can’t expect every single hospital to have like 5 anesthesiologists on call, 24/7, ready to show up in 5 minutes, in case there is an accident with several severely injured people that happens.
Sucks when it happens, but yea, stabilizing a potentially dying road accident victim is more important than giving a woman an epidural.
Reminds me of the one moment I considered home birth: I was pregnant in NYC in 2002-03. In my quest to consider everything that could possibly go wrong (because I’m like that) I asked my partner, “What do we do if planes crash into a couple more skyscrapers and they’re all busy at the hospital?” He said, “Well…we’ve got a bunch of towels here…” Fortunately for everyone involved it was only paranoia, but I do wonder what happened with women giving birth on 9/11/01 and whether any of them got pain relief.
Probably, if they got in. There were very few injured people. Either you got out, or you were dead.
A friend is an infectious disease doc, but was working at a hospital not far from the towers. When the planes it, he ran to the ER to wait (he may have had to run into the hospital). He figured he could help. He sat around all day, told me he and the other doctors ate snacks, waiting for the survivors to show up. I’m still chilled by his realization he said he came to later. “We can stop waiting for the survivors. WE are the survivors of the attack.”
True. It was a weird disaster in that way…usually you see a lot more injuries than deaths. I suppose the positive side is that there weren’t a lot of injuries from people trampling each other to get out of the way of the falling buildings and the (imaginary, as it turned out) other planes that were rumored to be on their way.
What chaps me is when we read or hear in a discussion that –
of course! – women can ask for an epidural (in the UK or the Netherlands, etc.). And then come the qualifiers:
“if you really need it”
”you might have to wait if the anesthetist is busy”
“the anesthetist could be in surgery”
”there is no anesthetist after hours or on weekends”
”that’s not available here; you must drive several hours to
a big hospital for that”
”labor has to be well established”
“if you are a good candidate”
All of these have to do with minimizing and de-prioritizing women’s
pain.
I could be wrong, but I think obstetric units in the UK do all have anaesthetist cover full time, not just office hours. The problem is that there aren’t enough of them, rather than them not being around in the evenings or on weekends. You also don’t usually drive several hours in the UK and especially not the Netherlands. I can personally attest to the truth of the rest, though.
Not all of the statements apply to both countries or to them equally. The Netherlands now has a stated policy that women can have epidurals. But not all women have access.
http://www.dutchnews.nl/news/archives/2010/09/not_all_hospitals_meet_governm/
In the UK, a goal is to consolidate consultant led units (there will be fewer of them). There’s no doubt about the intent of the NICE guidelines; they are heavily weighted in favor of women giving birth in birth centers or at home – and to the underlying philosophy that natural birth is superior.
Yes, there’s certainly a tendency to try and encourage women to go that way. Especially lower risk women. However, where obstetric units exist, they have 24/7 anaesthetist cover, just not enough of it, and I don’t see that changing.
I would argue that failure to treat women’s pain and healthcare needs are a truly false economy with a great deal of expense (although currently unmeasured). Women have higher rates of PTSD – is it childbirth related? What are the costs of PTSD in terms of lost productivity? And what of Post-partum depression? Is the message that women’s health and well-being “doesn’t matter” contributing to the development of PPD? And the downstream costs of failure to adequately treat women during birth? The costs of caring for brain injured children? The costs of surgical repair of childbirth injuries? When a woman is injured in childbirth, either physically or psychologically, there are costs that accrue in a myriad of ways – costs that should not be discounted. Motherhood exacts a toll, birth exacts a toll – there is a social obligation and responsibility to mitigate those tolls – to do otherwise is obscene and misogynistic.
Yes. I’m pretty certain it would’ve been cheaper for the NHS to just give me the epidural I wanted during my first birth, instead of spending time dealing with my complaint, keeping me under the midwife for a couple of weeks longer post birth because I was traumatised and needed support, and providing the two anaesthetic consults I insisted on during my second pregnancy.
I have to wonder, how anyone can talk about how the pain of childbirth is so traumatic that women “forget it” and not recognize that this is not a good thing much less a “virtue.”
I bet prostatectomy with lamaze would be less expensive too.
Vasectomy – simple outpatient procedure, not a ‘medical condition.’ If a man has proper support, he can be strong and get through it without anesthesia!
It certainly isn’t major surgery, by any definition! Actually, I think vasectomy is done under local. But I’ve never heard of a man being told that it’s not really pain and he can just breathe through the “intense sensation”.
I had Mirena placed about a month ago. The cramping was pretty damned painful. I wish I had at least asked for a Xanax, but I gritted my teeth and got through it (although I did take an Oxy when I got home that was leftover from my biopsy).
moto “Mirena placed . . . cramping was pretty damned painful”
I was told to take ibuprofen before I came in. Since it was my second one and I knew what I was in for, I did, and would recommend that for anyone having one placed.
Honestly, the reason I opted for the mini-pill instead of the Mirena is because I am scared of the pain during placement. I had a panic attack when they did the salpingogram or however you spell it, back when I was dealing with infertility. And yeah, I’m pretty infertile, but I don’t want to tempt fate, hence the bcp. My understanding is that they like to place IUDs during menses—but I don’t cycle, not even withdrawal bleeds, so I don’t know if I’d even be a candidate for this.
Salphingograms are pretty nasty. I had one during workup for subfertility too and it wasn’t exactly painful during the procedure, but I had to lay down afterwards because I was nauseous and cramping. Not a dam thing there either.
I thought it was painful during also – they had mentioned a couple of Advil, but I thought they meant after. Ouch. Sometimes being a woman bites.
I thought the salphingogram (spelling?) was worse than the IUD insertion. Heck, mine might have been as bad as delivering my second baby. I know it makes me cringe more thinking about it. Of course, in my case the dye didn’t go through one tube the first time so they pushed more in. It went through then, but I had to bite my tongue to avoid screaming and had nail marks on my palms for a couple of days afterwards.
Did not help me in the slightest and research isn’t supporting its ability to help insertion pain. Neither is cervical ripening with cytotec. My thought after having it in (took two tries, the Xanax made the successful 2nd attempt possible) was that epidurals should be the standard of care for IUD insertion! I’ve since had a baby and stand by my original statement. Damn but that hurt.
Well I did it without all those unnatural drugs so I could truly experience the sensations, and bond with my…wait. Anyway, I am clearly superior to you. /s
(so really, I forgot to take the ibuprofen beforehand and didn’t need it afterwards, and thought it might be good to know what it’s like for if/when I get to do them myself one day. Except for that pesky little issue of pain being so variable. I found it very uncomfortable, but manageable, whereas I’ve since observed one that was downright excruciating, and some others that were less so)
ANy reason for dilation of the cervix is excrutiatingly painful – the wider the dilation, the stronger the pain.
Thinking about the correction of an anterior lip-in the middle of a contraction that was already full on-still makes me physically shrink, more than 20 years later. Just when you think it couldn’t hurt any more…
I took ibuprofen for three days prior to insertion on the advice of my NP and had quit my BC pills a week prior. Those were both supposed to help make things more favorable for insertion. The cramps were quite bad for a good 3-4 hours after placement.
I guess I’m wondering if men would be expected to put up with this level of pain or would they be offered significant pain medication?
The dudes I know who had them got them under local. But nobody ever talks about how this local anesthesia is unnatural and how it’s important to feel the sensations and how you should bear the pain for the benefit of your wife, or the like…
The ‘surges’ of the testicular incision. I just want to hear someone try that.
The only issue with this is that my husband didn’t care if I chose to have an epidural and he certainly didn’t/does’t want to see me suffer. I feel the same way about him, so if we could just screen men for this misogynistic attitude, and see that only the ones who really deserve an empowering spiritual experience get it, that would be ideal.
If anything bugs me more than an unsympathetic health care professional, or NCBers chiding women for not being willing to “suck it up” during labor, it’s HUSBANDS who insist that their wives go through natural childbirth.
“It’s better for the baby.” “Remember, honey, you wanted a natural birth.”
I could really go Ninja on those men. They will never have the experience of birth, and haven’t a clue what their spouses are going through.
I’ve seen a couple like that on One Born Every Minute who came off as borderline abusive.
Every time we talk about birth, my husband’s response is “Just take the epidural”. I love him!
I was looking at the bill for my epidural and was wondering if it was worth the twenty minutes of pain relief I got and my husband quickly exclaimed yes. He did not like watching me in pain.
My husband cannot even stand to see me sick
Much as I did not enjoy labor pain, I was glad that I was the person who “got” to have the pain instead of being the one who had to watch and be unable to do anything to help. That really sucks.
Amy M, that is an awesome idea. 🙂
when I was dating, I definitely got potential partner’s opinion on birth control and abortion before we got ourselves into any situation where we might accidentally conceive a child. Maybe I should have added their feelings on my pain relief for my body. (My husband, fwiw, was like, “Um, as long as you don’t make me watch that needle go in your spine…” which was fine by me — I wasn’t planning on watching either!)
My husband had a local. Then was foolish enough to think he could tough out the pain when that wore off, for about 1 minute. The out came the ice packs and the pain meds. Actually, then the doting wife got them for him. Of course, he never tried to convince me to go through labour without pain relief. (That was all my stupid idea.) If he had, I might have let him suffer just a little.
We also don’t tell migraine sufferers to just “breathe through it” and “visualize a happy place.” They’re not going to die from their pain. But we help them relieve the pain anyway when they ask for it.
Actually, sometimes we do, or at least that was the medical advice I was given when I had my first migraines at 11.
Had my first migraine at 6 no one believed me. Had a few in teens and twenties. Then nothing until surprise! Menopause hit and I got a couple a week…I could not get my doctor to do anything…oh no …it’s you blood pressure..ummm no my pressure is through the roof because I M in so much pain. She went on vacation and the new doc gave me a prescription for preventative. So awesome to finally not be in pain.
Great to hear you got a solution!
And you’re right – studies confirm that high blood pressure doesn’t cause headache (except for now-very-rare cerebral encephalopahy or PIH/eclampsia). Like you say, the headache causes the high BP.
Well, I don’t know how old you are, but Imitrex and other effective yet routine migraine meds are pretty new — when you were eleven it might have been brand new or not available at all (or not approved for minors) if you are about my age. Or prohibitively expensive at 75$ a pill. Now, it is cheap and generic and there is no reason to not take it.
Thankfully the newer triptan-type anti-migraine tablets work specifically, so there is no need to be bonbed-out or vomiting on narcotics.
Intravenous meds like good-old chlorpromazine or prochlorperazine also work well.
Where I work, we have essentially elimiinated the use of narcotics for migraine – they never worked well, and we don’t have to worry about tolerance.
Well, my point was that most people don’t go around telling someone with a headache *not* to take Tylenol or Ibuprofen, which you don’t need a doctor to get. We’ve established that doctors have a tendency to not believe in women’s pain, so I’m not surprised if the same thing happens with migraines. I was only thinking of the scenario where everyone knows it’s painful (headache and labor), but with headache, people don’t tell you not to take the drugs available to help with the pain, whereas with childbirth they do. (Leaving aside those religions that refuse to use pain relievers for now.)
Actually my doctor told me taking painkillers since I was getting migraines constantly could cause a bounce back effect and cause more head aches. So I should take nothing for them…. umm yeah no.I have to work so over the counter pain meds is what I too when they came at work.
Bull. I was told that for years until I saw a good doctor who recommended me to a neurologist who found an issue that could have killed me before I was 40. But even after ER trips where I was in so much pain I was vomiting and hadn’t eaten or had anything to drink in days, I was told to just pop Excedrin. But then, I’m a silly female who doesn’t know anything.
My mom got accused of being a drug addict because of the horrific pain of her migraines. Stop and look for the cause of her multiple ER trips for intractable migraine pain? Why the hell would we do THAT? So much easier to label her a druggie and lecture her. While she’s vomiting uncontrollably and turning funny colors with tears running down her face.
For the record it was part hormonal and part from herher at the time undiagnosed celiacs. This went on for nearly fifteen years. Yay rural hospitals!
At my hospital they do vasectomies in the OR with twilight sedation! It used to be done in office with local but men wouldn’t tolerate the needles so now it’s a surgery in the OR. I’m sure that it costs a lot more money for the OR staff, etc. but no one’s saying men should have this procedure done under local again to save money. I’ve even seen devices specially created to deliver local anesthesia to the scrotum without needles using forced air! It’s all so mysoginistic.
http://www.ncbi.nlm.nih.gov/m/pubmed/15821547/
I did, jokingly, when my husband’s local anaesthetic wore off and he was waiting for the pain meds he’d held off on taking to kick in. He started it though, and then we had to stop because laughing hurt.
One of my uncles was whining about his post-vasectomy pain, and my aunt finally told him to shut up. She was recovering from an episiotomy. Ow.
I have had first-hand experience at how little a woman’s pain matters to the medical establishment.
Gather ’round, and I’ll tell you the story of when fluid started leaking out of my spine…and I was told I was being “over-dramatic.”
I was working in a hospital at the time. It was a bitterly cold winter morning, and while hurrying into the building, I slipped on a patch of black ice (yes, there was black ice in the hospital entryway) and fell on my back. At first I didn’t think I had been hurt, but I was sent to employee health just to be safe. An examination by the PA seemed to confirm that nothing was wrong, though when I complained of a headache, I was sent for a CT scan of my lower spine to check for damage. Again, nothing.
The headache gradually became worse and worse, until the pain became so severe and my neck felt so stiff that I went to the emergency department. Again, I got the same answer: It’s just a result of the fall, you’ll be sore for a few days, you’re fine, you’re fine, you’re fine.
When I got home, the headaches just kept getting worse. I felt no pain while lying down, but once I stood or sat up, I had terrible, head-splitting headaches, nausea, and stiffness in my neck. The next day, I found I could not keep any food or drink down, because I vomited up everything the moment I lifted my head. Back to the ED! My then-fiance had to carry me down the stairs to the car. Eventually the pain of holding my head upright became too much. It was a five minute ride to the hospital, but it felt more like five hours.
At the ED, they had me sit in a wheelchair. I was in so much pain that I couldn’t stop crying. Finally, I was able to lie down on a gurney and the pain and nausea stopped. A doctor – a young female doctor! – came in and said that nothing was wrong, I was just still a bit sore from the fall and I was “having a bad reaction to the pain medication” the PA gave me earlier. (!!!!!!) When I insisted that it had to be something else, she sneered and called me “over-dramatic.” Let’s review: Headache so severe I felt like I was being struck with an axe repeatedly every time I lifted my head, stiff neck, and vomiting…..and I was “over-dramatic.” I bet if I were a man I would have been whisked away to further testing within seconds. But I was “over-dramatic.” The doctor tried to discharge me, but I could not even lift my head to sign the papers.
I was extremely lucky to have both my parents and my fiance advocating for me in that hospital. Finally, after several hours, I was given a CT scan of my head, and another doctor confirmed that yes, there was something wrong, though he wasn’t quite sure what it was. I was admitted, and waited two days for an MRI. The MRI showed that I had a dural tear as a result of the fall.
A dural tear. That’s a tear in the membrane encasing the spine. Cerebral spinal fluid was leaking out of my spine. The resulting loss of pressure in the fluid and membranes surrounding my brain cause the headaches. George Clooney sustained a dural tear while working on the movie Syriana, and the pain was so severe that it caused him to consider suicide.
But, you know, I was being “over-dramatic.”
Happily, I was soon transferred to a better hospital, where I was given an MRI of my head, neck, and spine (three hours in that tube!). A team of neurosurgeons determined that I had had a cyst on the base of my spine, and the fall caused it to rupture, causing the fluid leakage. (Oh, and also spina bifida occulta, of which I was completely unaware before then). Luckily for me, I didn’t need surgery to repair the tear: Just lots of caffeine, both in coffee and in the pure liquid form (side note: pure liquid caffeine tastes just like the bitter, citrusy notes of a cup of black coffee) to restore the pressure in my head, and two weeks’ bedrest. I made a full recovery. That was two years ago, my spine is fine, and I learned a lot about whose pain gets taken seriously.
TL;DR: I slipped and fell and tore the membrane encasing my spine and the ED doctor called me “over-dramatic.” I don’t think anyone called George Clooney that after he had the same injury.
Not an ER doc, but that’s a pretty classic presentation. Particularly the positional headache.
True – along with the multiple presentations.
Always easier with retrospect, however. Sigh. I hate hearing stories like this.
Having said that, I don’t think I’ve ever diagnosed a dural leak in the absence of a puncture from LP. spinal or epidural. Either I’m missing it, or it;s very rare.
I had an ex boyfriend that I swear to god got his narcessistc jollies out of always having something wrong with his body. Some days it was back pain, others it was a swollen knee joint or a dislocated hip or really whatever he thought would get him the most attention.. It took forever for me to realize that there was nothing actually wrong with him because each and every time he went into the doctor for his pain he would be given physical therapy, pain drugs, and an MRI. During our five year relationship he probably had ten MRIs, twenty collogen injections, and one notable case where he swore for months that he had an ulcer and when the camera went down it turned out to be heartburn. Nothing wrong was ever found, and his doctor kept ordering tests and treatments and kept telling him that they would dig forever until they could find a reason because nobody should have to live with pain.
I went into the doctor with complications from a broken hand? I got told that healing takes time and I should take more asprin.
Thanks for sharing! It’s good to know that it’s not just me.
It took me…8 years, of considerably worsening pain, to get a diagnosis of joint hypermobility syndrome/EDS3 the complications of which now include severe pain in multiple joints, bilateral labral tears in my hips and very weak muscles. I kept going back and forward to the doctor, being told ‘oh it’s nothing’ ‘take painkillers’ ‘just stop dancing’ ‘you’re hypermobile, there’s nothing we can do’. In 8 years I had one x-ray and one MRI…the MRI was ordered by the consultant I begged to be referred to, the only one who ever actually listened to me. Seriously sucks to be a woman sometimes.
I went through the same thing. Nearly 15 years of pain and headaches before being diagnosed with Hypermobile EDS, Chiari Malformation, neck instability, tethered cord and autonomic dysfunction – Despite living in Maryland, where most of the EDS experts are! And I was initially “diagnosed” by my neighbor, a nurse who also has these conditions. She told me who to see to get a diagnosis. I often wonder how long it would have taken to get a diagnosis without her. My daughter inherited all these disorders as well and when she was waiting for her Chiari surgery, (diagnosed with MRI proof of Chiari), she had really severe head pain and her neurosurgeon sent us to the ER. He (NS) met us there and wanted the ER doc to admit her. I heard the ER doc tell our neurosurgeon, “I’m not admitting a teenage girl for having a headache during her period.” This attitude is a big problem. Not taking women’s – and teen girls- pain seriously is way too common. It seems to be the default position.
solidarity upvote not a ‘like’ that’s tough, I’m glad you finally got a diagnosis, and I also wish that doctors took nurses seriously (some do, which is fab) they are very skilled and often see a lot of stuff on a daily basis. Good luck to your daughter for the future 🙂
Way OT: Mattie, I hope you see this since you have Ehlers-Danlos syndrome (EDS). I’ve also seen a few others mention having connective tissue disorders or EDS here. I’ve checked this out (I’m an attorney now on SSDI), and it’s legit, as far as I can tell. Here’s the message:
“An Ehlers-Danlos syndrome (EDS) project to share the face of EDS.
““““““““““““““““““““““““““““““““`
“[Actor, Producer and fellow EDSers] Chas Scherer has come up with an awesome project for our [EDNF] fundraiser!”
He is asking everyone from around the world [with] EDS to record a video of them saying into the camera, ” I am the face of Ehler’s Danlos Syndrome…”
You can say it in any language you are comfortable saying it in. I would love it if someone could do the video in sign language (ASL). That would be amazing!
We can get so many people involved that way, and it’s free for them. Chas has a production crew that will edit and put all the videos together into one.
Please send your videos to Chas Scherer at chasscherer@gmail.com. Please send this on to all the EDSers that you know!
Thank you all!
****************************
From ForeverMe: As EDS patients know very well, we often appear healthy to observers, including medical professionals.** As a result, our very real complaints are often disregarded. This is why I believe this campaign could be helpful in promoting awareness of our under-diagnosed disorder. Please pass this along to any other EDSers who you know. Thanks.
Heh. We recently did a study here looking at wait times in the ED for people with painful conditions, trying to see if sickle cell patients had to wait longer than those with other painful conditions (short answer: yes). One side finding was that women consistently waited longer than men. Response from (male) ED attending was essentially, “well, that’s interesting.” No real interest in what this meant for ED policy or MD training, just noted and go on.
Oh man, sickle cell. My hospital was in an area with a high percentage of African immigrants, so I saw a lot of it. The worst was when a woman with sickle cell gave birth, which can trigger a crisis. Those poor women.
Among other complications. Did the woman you mentioned not get pain control during labor? I don’t have any real data to back this, but I feel like women with sickle who don’t get good pain control during labor seem to end up at high risk for nasty crises afterwards.
Most did get at least some, I think. Though certain members of the staff would constantly deride them as “drug addicts.” 🙁
Crappy disease. We can’t treat the underlying problem and the pain responds less and less to opiates over time. The only possibly good thing is that Obamacare has led drug companies to think that maybe they can make money on sickle cell disease now and start running clinical trials of new treatments. None that I’ve seen yet have been overly impressive, but at least things are being tried.
Anyone who drags out the ‘your body is perfectly evolved to give birth!’ needs to get hit in the face with a sickle cell. Yeah, their bodies evolved to be more resistant to malaria – at this price. Nothing is ideal in evolution (or free).
Sickle trait, though not completely “free” is a significant survival advantage in malaria prone areas. To the point that I once accidentally referred to people living in malaria prone areas who had “normal” beta-globin as having “AA disease” (A is what the normal beta-globin chain is designated on electrophoresis.) Disturbingly, none of the medical students called me on it.
So if you’re black you’re a drug seeker? Is that the stance?
And a waste of money. There’s this whole discussion about how to keep people with sickle cell out of the hospital. My suggestion of mining the ED entrance was rejected, but only because it might discourage insured patients unduly. Seriously, how are we supposed to keep people with a painful, chronic disease with only one, that is to say ONE, singular, disease altering treatment which is known to fail or be intolerable in at least 25% of patients in the best case scenario, out of the hospital without denying care? I’ve asked this in meetings, haven’t gotten an answer.
Oh, and if you’re female and black you’re a hysterical drug seeker.
Or Hispanic, Latino, or of Spanish origin if you’re on the West Coast. You’re also probably a drug dealer and a car thief. And lazy. *eye roll*
My husband calls it Schroedinger’s immigrant now after hearing it online: simultaneously sucking up all our unemployment and other benefits while stealing all our jobs.
Or the Arab students in the area who are either going to blow up the hospital or seduce all the single girls and fly them back home to be their prisoner wives.
The Western US still has a surprising amount of issues with “Brown” people.
The Hispanic side of my family has lived in what is now the southwestern US since the 1600s. They wax sarcastic on being called “immigrants”.
A lot people of Hispanic descent and the Navajo and Paiute here snark on the same thing. They’re like, “Dude! We’re here waaaaaaay before you whiteys! Get off OUR land, you squatters!”
It makes me giggle despite being one of those whiteys. But I’m also not telling them to go away. We could use a bit more diversity around here.
My family is pretty old American on all sides. Three out of 4 grandparents can trace at least some ancestors back to the 17th or early 18th century in the Americas. (Well, except for the one where the line kind of disappears in the southern colonies in the late 17th century. We can’t prove where they’re from, but if they’re not European descended we really have to reconsider Lamarck.) So I figure that I have as much right as anyone to say this: To any non-USians wanting to move to the US: Come on over, y’all. Plenty of room in this country still.
Yeah if people think there’s no more room to expand in the US, they haven’t driven through the Intermountain west. Wilderness for as far as the eye can see and that doesn’t include any of the parks either. They should build a high speed train in the more desolate wilderness there… It’d be awesome.
Trust me, there’s not much animal life out there to disturb.
I’d also like to see immigrants to revitalize some of the depressed cities around the US. Detroit comes to mind. NYC is different now than it was in the 1970s primarily because of immigrants coming in, building businesses (improved the economy), building communities (reduced crime), and generally making the place more interesting. Why not try the same thing in Detroit or Camden?
I like the way you think!
I’d rather invest in smarter density than more sprawl, personally. There’s plenty of room without expanding our footprint, and it’s more efficient in terms of infrastructure to have less demand for road in between points.
Very true. We really need more efficient travel between larger cities too.
I just like pointing out all the wide open space to people that say there just not enough room. I know resources are the real problem though.
Really what they should do with all the desolate open space is build some Gen III+ nuclear power plants. Not that they’re likely to meltdown in the first place and its almost an impossobility with non-Soviet reactor designs for a Chernobyl repeat but if they did at least they’d be far, far away from densly populated areas.
“Schroedinger’s immigrant”
Effing brilliant!
In this country if you are black you are a drug seeker, a welfare queen, a thug, a criminal. ..shall I go on?
But have mercy if you are black and can ask the nurses/ doctors intelligent questions. In my neck of the woods they either take issue with it or immediately want to know where you are from.
That’s disappointing.
In Australian Emergency Medicine, pain relief has become a priority, with nurse-initiated narcotics and audit of response times. It’s not perfect, but it stands in contrast to the “just put up with it” attitude. We generally teach the juniors that narcotic addicts get painful conditions too, and are more tolerant to narcotics. For those people we also emphasise non-drug modalities like elevation and splinting (for limb injuries) and other more effective drugs for migraine etc.
Ironically, we are now being criticised for over-use of oral morphine when people continue to take it in the community.
Can’t win.
This sounds like what my mom went through a few years ago. She had excruciating lower back pain for several weeks and thought she probably slipped a disc. She went to doctor after doctor, as the pain continued to worsen, only to be told “Welcome to middle age! Of course your back hurts!” She was in her early fifties at the time, and she kept saying, I know from middle age aches and pains, and I know this isn’t it, something isn’t right. Finally one doctor agreed to send her for an MRI. She went in Friday afternoon and the MRI showed a massive cyst on the verge of rupture on her lower spine. The situation was so serious that she was on the operating table at 10 PM on a Friday night- they said if they waited till Monday, the cyst could rupture and possibly cause waist-down paralysis. She’s fine now, and ever so glad she continued to insist something was wrong, rather than let doctors accuse her of being a middle aged whiner.
I had something like this with my mother and it was very eye opening. She has an extremely high pain tolerance- she got bit by a copperhead last summer and when I asked how bad the pain was, she put it at “oh, a 7 or so.” This was for a bite that landed her in the ICU with 2 rounds of antivenom, and the next night we went out for drinks. She started complaining of unbearable leg pain. She just kept getting told she had bursitis, needed to work harder at PT, etc. It developed to the point where she had been walking 18 holes of golf per day and now was wheelchair bound. When I went with her to the orthopedist, they treated her like she was drug seeking and kept telling her she just needed to take some ibuprofen. Her pain was so bad she was talking suicide if it never got better. She went to PT and they chided her for not working hard enough, moved her back, and now all of a sudden she has leg pain and weakness on the other side and then incontinence. Well, low and behold, when I finally saw the MRI, I flipped. She had a massive spondylolithesis with disk herniation into both nerve roots and centrally into the canal causing a caudal equina syndrome. By her being pushed to do more despite her extreme pain her facet joint just completely snapped and had just become extremely unstable I rushed her to a neurosurgeon who performed urgent fusion and preserved her ability to walk. She still has some mild weakness but can golf and now has no pain. All because she was being”over-dramatic” with her pain. If I hadn’t been around to realize what was going on she might have ended up paralyzed. Because she was an older woman on Zoloft.
This is so unbelievably unacceptable.
is that what rarely (I hope) happens to women post-epidural, I’ve heard them called ‘epidural headaches’ I didn’t realise they could happen from falling down, you are a very brave individual…sounds excruciating
I love how all the NCB-advocating doctors and midwives have decided that all women WANT an unmedicated birth, where they have an “empowering” spiritual experience. Of course some women want that, but I’m going to go out on a limb and say that most women want to go home healthy, with a healthy baby, and get through the birth with as little pain as possible.
I guess its easier to save money if you don’t actually consult with the patient population and if you make financial decisions in a vacuum. What if there was a movement, to deny men any pain relief for kidney stones? Kidney stones are natural after all, and those men probably have them because they ate a poor diet and didn’t exercise enough. It’s just pain, it won’t kill them. How much could be saved by insisting that men with kidney stones should just stay home and wait, because that kidney stone will come out eventually? We wouldn’t have whiny kidney-stone sufferers taking up resources in the ED, or taking up a doctor’s precious time, or getting medication that they could certainly do without if they just man up—I mean, knowing you can survive kidney stone pain is empowering!
Back when I had my booking in visit for this pregnancy, the midwives were really pushing me to sign up for the hospital attached birth centre rather than going through the birth suite in the hospital itself. They insisted on taking me for a tour, telling me how lovely it was etc. (and in fairness it’s very nice and probably a very good compromise for those who are into the whole NCB/homebirth thing). At no point did they ask what my wishes were when it came to pain relief or mention that my pain relief options would be limited by my location – I would have to transfer to the main ward for an epidural which based on my experiences working in various hospitals could take some time for logistical reasons alone.
What did you decide?
I am grateful that an epidural was available promptly when I needed it, and no one gave me shit about it. In fact, THEY suggested it because I was about to get some pitocin on board. This hospital also wasn’t Baby-Friendly, so I got no crap about supplementing with formula or leaving the babies in the nursery.
I’ll be giving birth in the main hospital – I want the option of an epidural! And personally having OT and NICU across the hall will calm me more than pretty surroundings ever will (although I hope I won’t need them, it’s good to know they’re there if I do).
That’s definitely good, where I am the midwifery led unit/birth centre is across the hall from delivery suite and the OR, next door to NICU, but that’s not the case for a lot of hospitals and really if something goes very wrong, seconds count.
My best friend opted for a hospital-attached birth centre and had a hellish experience, so I really glad that you’re going for the main hospital. The midwives in the birth centre didn’t take her seriously and didn’t give her a decent amount of nitrous, then tried to hold her off from transferring for an epidural. They also got her to push before complete, and had her pushing for hours.
Our hospitals were 30 minutes apart, and she lived slightly too far out of my catchment. I had the standard birth suite with CNMs, along with a much more comfortable and SAFE experience. (Australia)
And if you have complications that the stone is too big to pass properly and splits the ureter on the way down, it’s nothing to worry about! If that complication kills your kidney, well, some kidneys just aren’t meant to live.
OT but wanted to share: http://www.healthnewsreview.org/news-release-review/jama-news-release-oversells-benefits-of-breastfeeding-for-leukemia-prevention/
The paper itself is a bit of a fishing expedition. The authors create and dissolve groupings to see if anything sticks.
The bit that I find odd is that the authors mention that of the 18 studies, 10 included leukemia diagnosed before age 1 – and that those patients’ leukemias probably began prenatally and were unaffected by breastfeeding.
Knowing that, I don’t know why they didn’t exclude those ten studies out for all of the data analysis rather than schlepping them in and out.
Evidence Based Surgery Recovery: The safety argument against provider-led surgery recovery units is simple and
compelling: providers who are trained to prescribed pain relieving medications, are more likely to use them. Evidence has shown that in surgical recovery units without orders for pain medications, rates of pain intervention are significantly lower. Nearly all surgical recovery units have labor intensive requirements, such as monitoring patients in the PACU and IV pain relief options that require monitoring by nursing staff. By allowing for an analgesia-free recovery, patients may have a straightforward recovery and may leave the surgical recovery unit free of interventions that DO have risk.
I am just astonished at this clown. I look at where he trained, and I wonder how in the world he wasn’t smacked down by his superiors for this claptrap. If my math is correct, he’s sitting for his boards this year, and I hope his examiners give him hell.
He is?! That’s great.
According to his registration information, Shah only graduated medicine in 2009. He has no Board certifications.
How does he get to be an AssocProf? Do they have them in the cereal boxes there?
http://profiles.ehs.state.ma.us/Profiles/Pages/PhysicianProfile.aspx?PhysicianID=94492
In the US you take your oral boards after two years of practice post-residency. And Associate Prof is an entry-level position
Assistant professor and instructor are the entry-level positions. Associate is usually 3-5 years after assistant professor. He’s likely living off his “board eligible” status.
Ah, looks like he is assistant. Interestingly, he does not appear to accept any insurance. Either he’s not in practice, he hasn’t told the state of MA what he accepts, or he’s got a cash only practice.
I have no idea at all what his appeal is. I’m going to put it down to “charisma” and assume this is a neurotyp thing. (With apologies to the neurotyps here.)
Excellent post. Under-treating ‘women stuff’ seems to start with period pain, just to set expectations for the worse to come. :
What’s worse is how well they’ve sold this bill of goods to women, so they feel like they’re ‘giving in’ if they get pain relief, so they feel like they’re ‘doing what’s best for their baby’ if they avoid it. Turning it into a moral success to refuse pain relief, making women peer-brow-beat other women over it.
Unfortunately Dr. Shah is in poor company and the same things are frequently said about maternity services in Canada (women *should* choose homes and birth centers and midwives more often etc etc). Although in BC at least the health ministry is particularly confused as they are both pushing home/midwives as cheaper while at the same time they started funding dedicated obstetrical anesthesia services and greatly improved the obstetrical anesthesia fee guide. My head hurts from the scratching.
Do not try to figure it out…there’s a special set of forces that apply to government and the decisions that are made. Take it as a small mercy in an otherwise illogical approach.
I vividly remember this plaque on the wall of a church in Edinburgh, Scotland.
What about the ethics of exposing women (and their families) to perinatal deaths that could have been prevented at a hospital?
Even with the best-trained midwives (or OBs for that matter), emergent complications at home lead to fetal death at absurdly high rates because of lack of personnel and equipment.
How about we do ALL healthcare at home? That’d save a TON of money!
My oldest son will be six in a couple of months. I have NEVER forgotten the agonizing pain of his delivery. I replayed the final moments of delivery and the resulting complications over and over in my head for several weeks. When I had my first postpartum menstrual cycle, I actually had a few moments of panic because the relatively minor cramping I was having reminded me far too much of early labor. I know that if I had not stayed on my antidepressants throughout pregnancy that I would have developed PPD – even with them, I was right on the edge of the abyss.
It depresses me to think that women must continue to argue for their human right to pain relief during childbirth in the 21st century. It infuriates me that cost savings are of greater interest than the health and safety of mother and child.
I’m with you Moto. My youngest is only 1.5 yrs but I remember the pain and fear of his delivery very well…so well that I feel nauseous and anxious when I drive past the OBs office or the hospital I delivered at…and also like you I feel anxious and have a flood of very negative memories/ poor sleep every month with menstrual cramping. So much so that I think I need to suppress menstruation for the sake of my mental health.
I’ve been skipping withdrawal bleeds for years with NuvaRing. Occasionally I have very light spotting. I am thinking of doing a withdrawal bleed just to get all that stuff out but honestly there is not a week that passes that I think “Yeah, this is a great idea to expel some uterine lining”
You’re good! Your uterine lining is probably quite thinned out from years of hormonal contraception. If you needed to have a withdrawal bleed, I guarantee your uterus would let you know 🙂
I hate that you are in this club too, adequatemother.
My daughter turns 5 this July. I fear I will never forget. The best I can do is speak up for the right of others to have adequate access – it is the only thing that can be done.
“A mother forgets the pain…” That is crap. I will never forget clinging to the side rail of that bed, pressing my forehead against my knuckles and thinking “Wow, wouldn’t it be easier if I just died right now?” For months afterward, the thought of becoming pregnant again filled me with fear.
Bless you, Epidural Lady, wherever you are now!
I can’t clearly remember the pain, but I do remember begging for help and feeling helpless and torn apart and being in agony. Does that count?
Absolutely!
Me either. The idea of getting pregnant scared me so bad that I got my tubes tied and made my husband get a vasectomy. And I sure as heck made sure he went back for all his semen sample tests. And I got an epidural pretty fast. But just the pain and agony as I had the first contractions was bad enough.
Bravo, Dr. Amy. One of your best blog posts in a long time.