As I say in the video, I’d rather save babies.
Author:Amy Tuteur, MD
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137 Responses to “Dr. Amy on HuffPo Live: Do you want to save money or do you want to save babies?”
Amy Tuteur, MD
Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com... More
My baby was born in Japan, one the best rated in the world in Maternal and Child mortality rates. I was in the hospital for ten days with a c-section and it cost $10,000 total – for everything. The care was amazing! The hospital was amazingly high tech, only had private rooms and offered foot massages and parenting classes. I can’t imagine what that would have cost in the US!
For the record – standard care for a c-section is ten days to two weeks in Japan. Also, I was attended by a midwife who was there for moral support. The c-section rate in Japan is 17% however the induction rate is much higher, Japanese doctors get very nervous if anyone goes beyond 40 weeks and that is because they are very worried about stillbirth.
“My baby was born in Japan, one the best rated in the world
in Maternal and Child mortality rates….”
“Japanese doctors get very nervous if anyone goes beyond 40
weeks and that is because they are very worried about stillbirth….”
Here’s to doctors getting nervous – seems to work. If both coming out alive is your priority, that is. If it is avoiding “interventions” then of course you need braver, more maleable doctors.
My great-niece is 39 weeks with her first child. Under the care of midwives, in one of our many failing hospitals. Her ankles are swollen, but hey ,it is hot, and everyone’s feet double in size. It will come as no surprise if she is “allowed” to go to 42 weeks. I am praying she won’t, and I’m a heathen!
Always reminds me of a Holmes on Homes episode. When Holmes comes into a house after lay renovations have been done for cost savings only to criticize everything that was done and how he has to do everything over. No cost savings there. And at least he can do things over to code at the expense of cost only. With pregnancy, you only have one shot, if you screw up the management of that pregnancy, babies die.
One question at present I can see it’s pretty hard to. : ((((((((((((((
What is it about NCB spokeswomen that they have crooked teeth and hair from hell? In addition to the nut job on here, think IMG and CW.
LOL and I wanted to yell at the screen when she would get that little smirk when the moderator scolded Dr. Amy for talking about whether or not interventions saved lives and not money.
I thought the same thing, but I didn’t have the balls to say it.
On second thought, maybe the answer is obvious. Let tooth and hair grow the way nature intended it. Orthodontists and hair stylist are just money grabbing interventionists.
Shouldn’t that title have a question mark?
BTW I love that host.
This BS scares the shit out of me…….Take away the drugs and labor is cheaper. Fuuuuuck. What does that do for people like me who have sever anxiety about labor pain?
*HEADDESK*
We could save even more healthcare dollars if we removed the choice for pain relief for a lot of other procedures too. Passing kidney stones, migraine headaches, dental fillings, simple fracture reductions, removal of minor skin lesions, punch biopsies…
Aren’t pain killers among the most prescribed medications? Vicodin, for example?
I don’t know, but I wouldn’t be at all surprised. I imagine those PCA machines for post-op pain don’t come cheap, either.
I looked it up, and I was right. Vicodin is the most prescribed drug, and is prescribed almost 50% more often than the 2nd place drug (Zocor)
Maybe the reason midwives cost less (and I am talking about CPMs) is that they are willing to accept trades like the ones mentioned here http://www.foothillsmidwife.com/#!billing/c1s05
She has attended 160 births and takes “up to” three clients a month. She attended Bastyr.
In case anyone doesn’t want to listen to it, I will summarize it:
Other interviewees: Childbirth in America is so expensive! It would be cheaper if we didn’t do so much to manage it and instead left it to nature and to less qualified providers!
Dr. Amy: Actually, all US medical care is expensive, not just maternity care and…
Other interviewees: Childbirth in America is so expensive! It would be cheaper if we didn’t do so much to manage it and instead left it to nature and to less qualified providers!
Dr. Amy: Actually, if you move to midwifery models you have much higher death rates…
Moderator: That is off topic!
Other interviewees: If we didn’t C-section/induce as often, childbirth would be cheaper. Midwives don’t c-section or induce as often as OBs.
Dr. Amy: If you lower the rate of inductions, you increase the rate of stillbirth. You can either save money or save babies. I want to save babies.
Interview ends.
Ugh!!
http://www.cnn.com/2013/07/09/opinion/declercq-childbirth-costs/index.html
Agree. UGH!!! Why the push for midwife run free standing birth centers? Why would I want to give birth where emergency surgery can’t take place? Why would a mother want to prevent epidural option? What is the attraction for low-tech care? Is this somehow to punish low risk healthy women by offering them less technology?
Since when is giving birth like going to the DMV?
I wish Amazonmom could tell some horror stories about the transfers she has seen from the birth center near where she works.
I have the stories but it would obvious which patients I’m talking about. Lawsuits are pending in some.
Eugene Declercq, nope. Don’t even need to read this one.
Dr. Declercq is a condescending boob. “Those spoiled US women wanting latest treatments, brats!”
Why wouldn’t we want the latest scientific advancements? It’s called progress!
Hmm, let me see:
Hospital: availability of OR, NICU, anesthesiologists, neonatologists, surgeons, 24 hour monitoring should something go wrong.
Birthing center: a pool, and a midwife, birthing stool.
How about universal healthcare to lower costs? Why does go over every other possibility except the most obvious one? Oh yeah, because we are American and we don’t do that universal-commie stuff…… We also don’t travel in order to know what we are actually missing…….
My favorites
At 8:10
“That’s another conversation, which is an important one to have. One thing for sure, outcomes… are one aspect of this, cost is certainly another. And I think that’s what we are here to discuss today.” Is this how all midwives begin their prenatal care discussions with their clients? Midwife to client, “Uh, outcomes are not important here because you are going to save so much more money by having me deliver your baby.”
At 15:45
Thanks Tina for your excellent evidence based analysis… The truth that everone knows iust from being alive today, the C section rate among American women has skyrocketed in last decade, the induction rate has skyrocketed in the last decade, and the cost of birth has skyrocketed, heh, so in our gut we know that these things are connected. So go buy my book for more simple deductions I came up with. Like the use of smart phones have gone up and the diagnosis of autism has gone up, so the smart phones are causing autism. How about the cost of inflation has gone up, the cost of physician and hospital overhead has gone up, the cost of malpractice insurance has gone up, the cost of taxes have gone up, the reimbursements for health has gone down, so these are connected to the cost of birth going up Tina.
At 17:10
Despite the moderator continually interupting Dr Amy to keep her from changing the topic from ‘cost’ to ‘midwife outcomes’ she allows Tina to blatantly say we should allow the model of care to be changed to allow universal midwife care for all. Tina states that cost and outcomes are better with midwives even after Dr Amy just has quoted the Netherlands study saying it is not. Was Tina even listening?
The costs of ALL medicare has gone up significantly in the last decade, not just childbirth. How do inductions and c-sections cause that?
Our insurance is pretty much “major medical” now. Very high deductible. I had to cancel a colonoscopy a few weeks ago. I’ve had polyps so it doesn’t count as preventive care, so the bill would have been almost $3000. We’ll up our HSA next year and schedule it then, even so probably do a payment plan.
How cost could be divorced from outcome in healthcare is beyond me. Or has HuffPo been bought out by Fox News?
LOL. Call me sick but I was thinking if Dr. Amy talked about the cost savings involved in the medical care of a dead baby vs a live one, never mind that they are cheaper to society that she would have let her keep talking…..
I gave birth with CNMs who worked under OBs. The universal cost for a vaginal delivery was the same for both, so I don’t see how having only midwives would save money, unless you want to use CPMs and have inferior care.
The CNMs I delivered with were very medically minded and didn’t want to take *any* risks if they didn’t have to. When I became high risk, there was no question about inducing me early. The OBs knew what was going on with me the entire time and were at the ready for anything that went wrong. Thankfully, everything went smoothly and I have a healthy 16-month-old today.
(Ding ding ding)
I hope that “ding ding ding” is a good thing…
The moderator for this debate was awful. She was very clearly biased, and failed to get both sides of the story. I am amazed at Dr. Amy’s patience.
OT–Today’s Kevin M.D. has an article in which pediatrician Roy Benaroch succinctly demolishes Jennifer Margulis’s “ultrasounds cause autism” article.
The “anchor” of this report is so wishy washy it makes me want to throw up.
I love how the 2 other chicks talking are so loud and cut off Dr. Amy. Such entitled folks. What you do expect from HuffPost?
I feel like I must comment on costs. OB physician renumeration is fixed. There is a global fee paid for all care including delivery. Yes there is some more money paid for C/S and or high risk mothers but this is not so high as to be the prime driver of OB care costs. That resides in the hospital and system. Hospital costs are driven by malpractice, pay for RN’s, etc. Changing care from midwives to OB will increase bad outcomes without having much impact on cost since most women will still deliver in the hospital and the costs will be much the same. Without tort reform costs will not change much. And there is no incentive to change the system.
Did you mean changing from OBs to midwives?
I meant changing from OBs to midwives is unlikely to have any significant change in costs of OB care as provider cost is the smallest portion of the cost of care.
Okay, that’s what I thought. Thanks for clarifying! 🙂
OT: You know, if all paper abstracts were this clear and concise, it might not be as much of a problem.
http://io9.com/this-may-be-the-best-scientific-paper-abstract-ever-wri-729221070
Best. Abstract. Ever.
My six year old is asking me why I am laughing so hard.
This is a tad off subject but Dr. Amy have you ever thought of introducing legislation that would require US midwives to be held to the same standards as other countries that you have mentioned and would require every practicing midwife to carry some form of malpractice insurance/ professional liability insurance? I don’t think most law makers are aware of the problems that arise from some of these midwives ineptitude leaving women with no legal recourse.I can’t imagine it would be difficult to find support for something like this.
The mod should have asked Dr Amy about her ideas for reducing cost and maintaining safety. Then it would have been a real conversation.
When I was interviewed by the producer several hours before the broadcast, I predicted exactly what would happen.
I told her that despite the fact that costs for EVERY medical intervention in the US is high, Norsigian and Cassidy would attempt to blame the cost on “unnecessary interventions.” I told her that one or both would reference the Birth Center study and then angrily denounce me when I took it apart. In fact, just about everything I predicted happened exactly the way I said it would.
I was pleased that I was able to make the point that you can read the papers yourself and make your own decisions. You don’t have to take my word for it.
And I was very happy to get in the last word: Do you want to save money or do you want to save babies? Personally, I would rather save babies.
I liked the way you said several times “may I please respond”? It highlighted both how rude all the interruptions were and how polite you were being towards the others. Take that, tone trolls!
As Dr. Amy pointed out, The Childbirth Connection is one of
the sponsors of the report on maternity costs cited in the interview. I decided
to visit their site to get an idea of where they are coming from, and found
this “must reading,” Two Births (one good, one bad):
http://transform.childbirthconnection.org/wp-content/uploads/2011/03/vision-allegory3.pdf
I guess they wouldn’t like the story of my second pregnancy, the one with an attentive OB and a euphoric epidural birth.
OMG what propaganda. And drivel, too.
If the topic was MENs bodies and health, cost wouldn’t even come up.
Especially if it had to do with their DICKS.
No amount would be much big to make sure MALE genitals stayed functional and pain free!
ALL plans cover Viagra, but not BC, and we don’t see men with penis issues being treated by lesser than HCPs….
Womens health care should not be looked at at a place to save cash by substituting lower skilled workers.. This NOT OK. Models with MWs are in NO WAY superior, and I have no interest in having that care in the USA. Maternity is one of the things we do well, and I want it to stay that way.
It’s true-how many men settle for drinking herbal tea to solve prostate problems? How many direct entry urologists who studied via correspondence course and then apprenticed with a another direct entry urologist do we see? There are no prostate health affirmations, suggestions of warm baths or counterpressure to ease pain and there are no doulas that accompany men to the hospital when they getting procedures done in an effort to help them “not cave” when it comes to pain medication.
Bear in mind that the male model of medical stupidity is to 1) not take care of self 2) not make or go to medical appointments.
“A recent poll of 1,100 men showed that even under the best circumstances — when men have health insurance and have a primary doctor they feel comfortable talking to — 58% say that something still keeps them from actually going to the doctor.
“The biggest problem with men’s health is, well, men.”
http://www.askmen.com/top_10/fitness/top-5-reasons-why-men-dont-go-to-the-doctor.html
I am married to a man like this. He had to be dragged in when he broke his arm- he was gonna splint it and leave it!
But when they do go in, they see doctors. They get their pain relieved. They aren’t told to get a support person and go “natural” or to see an uneducated layperson.
My husband too. He was playing soccer with his adult rec team, when he injured his knee. It was the swollen to three times the size of his other knee within 15 minutes, he couldn’t bend it, and couldn’t put any weight on it. I asked if he wanted to go to the ER, or make an appointment with a doctor the next day (it was a Sunday). He said he wanted to see how it felt in the morning before calling a doctor. Next morning, he wanted to give it a bit more time before calling. He finally made an appointment mostly to shut me up. Result? Broken knee cap and partially torn MCL. He wouldn’t take anything stronger than ibuprofen either, even though the doctor offered the good stuff.
Dear OG, MEN!
Example: a man who had a dense hemiplegic stroke, and who only went to A&E (and got lysis, and is now fine) because his wife insisted. He had just wanted to go to bed and see if he felt better in the morning.
Or another man with a fungating skin tumour on his scalp who only saw a doctor when the cap he had been using to cover it would no longer fit over it.
Or the man who was literally dragged to his GP by his wife after losing 18lbs in four weeks and who had a pulse rate of 150 from his hyperthyroidism.
And this is the NHS, where cost isn’t an issue!
If I see a man who hasn’t seen a GP in 5 years and he tells me he’s “fine” he’s probably seriously unwell, and he isn’t leaving my consulting room until we work it out.
oh.em.gee
fungating tumor too large for his cap?
I don’t think anything could prepare me for that.
I have a varied and interesting working life 🙂
GP is…well, you see and hear a lot of weird stuff, and quite often, you wish brain bleach was a real thing.
The trick is to be empathetic, professional and unshockable.
When I was following my dad around as a teen a patient came in who had gotten caught in a sugar cane crusher. He had lost a large portion of the skin on his right arm and leg. His wife had to force him to go to the ER because he felt that he would be fine and she was overreacting. He wound up spending weeks in the hospital getting skin grafts and physical therapy. I can only imagine how much worse it would have been if he’d waited like he wanted to and had infection set in before he came to the hospital.
There was another gentleman who came in paralyzed from the waist down. When asked whether he’d had any symptoms suggesting there was something wrong prior to the paralysis, he insisted he had not. Until his wife pointed out that she’d asked him to go see the doctor weeks before when he started getting numbness from the waist down.
This is why I am glad my husband is in the military. Checkups are mandatory. I don’t have to nag him that is his CO’s job.
“how many men settle for drinking herbal tea to solve prostate problems?”
A lot actually. Saw Palmetto is the herb of choice. Randomized controlled studies show it doesn’t work and yet a number of my patients continue to take it.
There’s also prostate massage apparently…
Come on, Joe Theismann is on promoting Super beta prostate is better than saw palmetto. Haha
“ALL plans cover Viagra, but not BC”
Actually this is mainly a myth. The erection drugs have very poor coverage in general. *Most* plans cover birth control pills with just a regular co-pay and no pre-approval needed. This is not the case for Viagra.
I stand corrected!
Though every guy that admitted to using it was able to get it, and its available on many plans where BC is banned.
Stacejw has been corrected on this before. I don’t know why she keeps repeating this nonsense.
SO much hate on doctors. Everything is all about their convenience and greed. And they may as well have put a gag in Dr. Amy’s mouth for how much they let her actually give her point of view.
What kind of health insurance doesn’t cover maternity care? Did the women know they did not have coverage or did they find out afterwards? How can that even be legal for insurance to deny maternity cost?
I am referring to the article in the NYTimes lamenting the high cost of USA childbirth as compared to other industrialised nations.
The answer coming from the pundits seems to be that here in the USA we rely on ob/gyn’s rather than midwives and here in the USA we do expensive pre-natal testing without better outcomes.
Dr. A says our outcomes are not worse.
Individual plans never cover maternity, unless you add it for 6mo to the tune of 1500 a month. Its insane. If you have employer provider coverage, or get Mediciad, birth is cheap to free. if not, you’re screwed.
This is exactly right. In fact, I have both types of coverage…I have a single plan through my employer that I pay nothing for, and maternity costs are covered. The separate policy I took out for my daughter and I, does NOT cover maternity costs whatsoever, and it costs a pretty penny.
Some states now require maternity care to be included: individual plans are more expensive there.
With many plans, if you only add the maternity rider after you’re pregnant, it’s too late.
Maternity rider has to be added one year before you plan to get pregnant (according to the plan that we looked at). Which is ok if you can plan, but if you end up pregnant without that maternity rider you are ending up paying everything out of pocket.
I suppose that’s better than how things worked in the Mad Men era, where (according to my mom) you could only buy maternity insurance if you were married.
Preconception planning. Get the insurance needed, see your doctor for a visit, start prenatal vitamins. Who does this anymore? It’s all pay for the cheapest health insurance, noncompliance with birth control, then blame the doctors for skyrocketing cost of birth. I am writing a book now, haha.
The cost of a brain-damaged baby who needs 24-hour care the rest of its life costs more than a C/S.
I am a firm fan of this site, and I am grateful to Dr Amy for dissecting the arguments of the NCB crowd, my opinion of which doesn’t have to be recorded, as I live in a particularly crunchy community.
But I do have an honest question. I have given birth both in Britain and in Israel, where the model of care is identical. Women are attended by midwives, but there are always OBs on call if a medical issue goes beyond the scope of what a midwife is trained to do or provide. I have never seen midwives refusing or hesitating to call a doctor if things start to go pear shaped; in fact, they all seem to work together seamlessly. And all the technology that is available and used in the USA is used in exactly the same way. So what is wrong with this model of care? Why are OBs so much more involved in births in the USA, which raises costs? Are the outcomes so much better in the US than in the UK or Israel?
Again I am not out to say that the costs of care in the US is pocketed by the ‘greedy doctors’; I genuinely want an answer.
I agree with the caveat that pain relief must be offered to any woman that wants it. I’m afraid that any plan to change our model of care will also result in epidural denials.
Also, we can’t change the model of care without tort reform. Since the standard of care currently uses tests and procedures that save babies in rare instances, it has become actionable for parents to sue if “something” was omitted and they suffered a loss or baby has damage. Take those away in the name of cost-cutting and there will be more of those loss parents and damaged babies.
Oh, I meant to include one more condition – US midwives must be trained at the graduate school level as are those in Britain and Israel.
I think the subject of suing could be the big factor here. Suing the doctor is a very done thing in the States, but those that do so are really shooting themselves in the foot. Because of it, the doctors are forced to take out exorbitant insurance plans, so the charges for their services are obviously going to go up. In Israel, where I now live, the way the legal system is set up makes it practically impossibIe to sue, and not just doctors. A man who smashed his face in when he tripped and went flying on an unstable sidewalk wanted to sue the city hall, but was advised not to even bother trying. “What do you think this is, America?” So no Israeli parent is going to sue because a rare test was omitted either.
The point about the education requirements to become a midwife is a good one, and explains a lot about OBs being around deliveries much more in the US. A CNM is not as qualified as a midwife in other countries. But the higher level of education needed could be introduced slowly; it doesn’t need a major overhaul of the whole system.
Higher level of education – that was the original intent. The CPM credential was meant to be a bridge for those midwives at the time to continue practicing while they increased their education, and new ones would begin with the graduate level knowledge.
Unfortunately, the opposite happened.
I think people see one or two outlandish cases and assume all lawsuits are similar. This is not the case. The ability to sue for a lot of money is a GOOD thing in the USA, NOT a negative. Without it, there would be so many more deaths- no one gets sued when things go well. It keeps docs from taking short cuts, and keeps them adhering to the standers of care.
Besides, whats wrong with rare tests being offered anyway? Whats rare to you may not be so rare to the baby it saves. No harm in offering. It’s also not a cost issue, as there are other places we could save cost without sacrificing quality, like end of life care. taking money from maternity is penny wise, pound foolish.
But some doctors do perform C/S out of fear.
Of course they bloody do! Fear of a bad outcome leading to being sued.
You may prefer the fearless, happy to take a chance with your baby and their career, but not all of us would. It is a reasonable gamble, but the stakes are very high.
I would have more respect for those who resist CS in dubious circumstances if a) they really were informed about what they are risking and b) it was their own life they were gambling with. Those who say “but I didn’t really understand it could happen to me” or “look, look, everything is OK, there WAS no risk” are idiots in my book.
Thats just not enough education to lead a birth team, IMO, Birth is SO DEADLY! Why would you want less than an OB? Save the NPs and grad school programs for other places in medicine. But birth is way too dangerous for that.
I know there are places where MWs are great, and we have wonderful CNMs, but I just don’t see why we would aspire to a system staffed by them. No thanks.
There are places and programs in the U.S. where doctors and
midwives work together cooperatively. That model isn’t available everywhere. And there are some rogue midwives out there practicing abysmal care.
I support women having a choice between OB care and midwife
care (overseen by a doctor). Midwives need to be licensed, educated, insured for liability, and practice in safe settings. Doctors already must meet these requirements.
Personally, I wanted an OB for care in pregnancy and
especially at birth. For the most important day – medically – in my babies’ lives, I wanted a doctor. I didn’t want one who was simultaneously responsible for dozens of other patients in a ward; I wanted a doctor dedicated to my care and that of my baby.
Is that an extravagance? I hope not.
I don’t want a MW. I want an OB. Why should women have a lesser care provider on the MOST dangerous day? and yes, even UK MWs are inferior to OBs.
I don’t want a MW either. I want an OB. I am way more comfortable with the risk tolerance an OB has and their non-denialist approach to the fact that birth has complications. Our Canadian midwives are university trained and work in an integrated fashion with the rest of the health system. But they still ideologically have this idea that birth is “normal.”
I don’t share that belief.
All of the three intrapartum deaths I’ve seen during my medical training and practice were MW patients. Two were inappropriate interpretations of FHR and delayed OB consultation. The third was a HB transfer after cord accident.
I have zero interest in having a MW.
Yup, I’m a crappy candidate for a mw anyway even in Canada. I had a c-section first birth, I’m over 35 and I have no desire to have a vaginal birth.
I’d much rather use an OB.
And access to OB care is a serious issue in Canada – where I live (Victoria) a woman has to advocate strongly for a “shared care” model and referrals tend to be made around 32 weeks with actual appointments not happening until 36 weeks. If a woman in Victoria wants an OB to care for her during her pregnancy she must be willing to travel, either up island or to Vancouver. Apparently continuity of care is something that only those who desire “normal” births deserve in Victoria, and that is sad.
Victoria is the capital of British Columbia, for the non-Pacific Northwest readers, which I think makes Mrs. W’s story worse.
Victoria is a hotbed of natural childbirth and woo as well. There are lots of yuppy back to the landers on the island…and they have something like 20-30% of births are attempted homebirths there…in spite of having an elevated average age for primips (was > 35 the last time I checked).
I work in Victoria and it is a hot bed of woo!! Right now a out 25-30% of women are seen and cared for primarily by midwives. About 15% of those women attempt home birth. 12% of our women are over the age of 40 and another 18% over he age of 35. We have one of he highest c-section rates in Canada. I think our model has some pluses, but access to OBs is strictly limited, you must have a referral. Depending on who you maternity provider is, that can be difficult. We have some of the best midwives and GPs I have ever worked with, but others are getting deeper into the woo. We even have patients who tell us, in person, hat they are going to have a second opinion with Gloria Lemay!! It has been an experience moving out here.
They want to consult with a criminal who believes women should birth standing because elephants do? I didn’t realize Gloria Lemay was in Victoria now, last I heard she was teaching “midwife classes” online and at the Kits community center in Vancouver.
That’s horrible. Not meeting your doctor until 36 weeks? Do you at least get an OB if there are complications before that?
I believe if you are high risk then you may get referred sooner.
Personally, I don’t think there would be a problem with a system similar to the NP model that is currently used in the US. “Nurse practitioners” are advanced educated, and work under the supervision for a doctor. In the end, they are working as a vehicle for the particular doctor, and ultimately the doctors are responsible for their actions, and therefore, they need to do it the way the doctor wants it done.
The reason this hasn’t happened in OB, I think, is because midwives don’t want that model. They want to be in charge, and not beholden to the doctor. Basically, they want all the authority, but at the same time, none of the responsibility. Doctors are not going to be willing to work with a midwife who insists on sole authority, knowing that doctor bears all the responsibility.
As has been noted, there absolutely are clinics where this type of arrangement is going on, where the midwives work in consort with the doctors. Unfortunately, there aren’t enough midwives willing to do this to make it the standard approach.
” “Nurse practitioners” are advanced educated, and work under the supervision for a doctor. In the end, they are working as a vehicle for the particular doctor…”
Just wanted to say that this isn’t technically true. NPs do work autonomously and it can vary state to state with some allowing more than others and some taking a graduated approach such as 2 years of supervised practice first. I know here in Canada we have NP run clinics, especially in isolated areas, that certainly refer patients to MDs but are not under the authority of an MD. So while there are certainly many practices where an NP works alongside a physician, the idea that they a a vehicle for a specific MD is actually a common misconception.
Here in my state NP and CNM have to have a collaborative agreement. No autonomy. If the doctor doesn’t like what the NP is doing against the agreement, then the relationship can terminate. No misconception. Just regionally different.
Why do you mention Canada when we are talking about the model for medical care in the US? I really don’t understand that.
I don’t get this belief that midwives (even hospital midwives) are magical and if we just switched from obs to midwives, everything would be fixed. That was the message that I was getting from the other panelists. Most hospital midwives I’ve known do a fine job and hand over care when the stuff hits the fan, but if they are doing their jobs right, there should be no difference compared to what an ob would do, so the whole -midwives fix everything- idea just seems so stupid. I do get how having an in hospital delivery staff instead of an on call ob makes sense and cuts costs in urban centers. That model worked fine for me. I just think it is so misguided when I hear friends tell stories of how their midwife heroically stalled, so that the ob didn’t get a chance to use the forceps when my story is of the midwife who heroically stalled and delivered a blue, limp baby. If we deconstruct the -midwives fix everything- meme, it is just another version of -technology and preventative medicine are bad, it is better not to know than to take measures that might prove unneccessary.- To me, this advice sounds like -put your fingers in your ears and pray to the midwifery goddesses-.
At my last birth the midwife didn’t react quickly to decels in my baby’s heart rate and delivered a blue, limp baby. To her credit, as soon as she realized that she couldn’t revive him she pressed a panic button and a team of NICU doctors came flying in and did resuscitate him. Baby is almost three and fine, thank God. I’m going in this Friday to be induced and this time I chose an OB. I’ve told her, “Please, at the first sign of decels, go STRAIGHT to a c-section.”.
best wishes!
I’m not sure how the midwife model saves money. Their prenatal visits are 45-60 minutes. The one on one care that women expect during their labor and delivery means that you need a heck of a lot of midwives. Do we pay them the same per delivery and expect them each to take less deliveries? Or do we expect them to shoulder the same case load as an OB would and pay them less per delivery?
What about the cost of training them? University is subsidized here…students (much as they complain about high tuition) don’t pay the full cost. What about the costs associated with having student midwives in the hospitals? It costs money to train physicians. Its going to cost money to train midwives too.
I just don’t see how it saves money when you have to spend a bundle to educate a bunch of mid-level practitioners who are then going to do less work than the physicians they are “replacing.”
In terms of having a back up OB on call, that is already the model we have in Canada (for all non-OB patients that come into LDR). That physician is generally paid a combo of a cap rate (a fee for being on call) and fee-for-service for the work they do on call. If you took away an OB’s low risk vaginal deliveries, they would soon refuse to take call and probably switch to GYN practice. A night of call means two days out of the office or OR for an OB/GYN which is a significant loss of income with no loss of overhead costs. With high overhead, including high malpractice insurance, the cap rate for covering the midwifery unit would have to be increased. Or the result would be that call would be covered primarily by residents and new grads. Oh yeah, that sounds better for women and babies.
The ROI on maternity care, no matter how expensive it is, is HUGE. A dead baby costs society a ton in terms of future productivity. A damaged baby that needs 24/7 specialized care costs even more. Even the NICU, as expensive and specialized as that care is, has a great ROI for socieity.
If we want to save money, we should limit futile (please note the use of the adjective “futile” here) ICU care for the elderly because that is a huge chunk of health care costs in the US.
That and the administrative overhead from having multiple insurance plans…which is something like 20% of costs compared to 2-5% of costs in places where the insurance plan is universal.
Adequate – the only way I can see midwives saving money, while not compromising quality of care would be if they were used as physician extenders. Basically as someone to do what the dental assistants do for the dentists – note such a role could just as easily be filled by nurses. But that is not the case – at least in Canada. Midwives want to be seen as independent for the most part – as such they are not “extenders” but rather just another type of pregnancy care provider with a limited scope of practice and a very limited volume of patients (which makes me nervous).
I am reasonably convinced that the midwifery model of care really only saves money in the brief pregnancy – 6 weeks post-partum period, largely as a result of avoiding the costs of epidural anesthesia and a greater willingness to forgo standard testing (gestational diabetes, etc.). As a result the longer-term economics of midwife care might actually make it the less cost-effective model to follow.
That being said, I am sure that there are efficiencies that could be found, and ways to improve the cost-effectiveness of maternity care without resorting to a lower standard of care. However, to get there, there is a lot of ideological bickering that needs to stop AND the focus needs to shift away from technology=bad and NCB=good to those things that really do matter to women and their children and have the real potential to make a difference in the long run.
I work in a model where the OBs don’t see the ow risk model. It reminds me of the British system, but I am in British Columbia. In the bigger centres here is enough work to go around. I am often so busy on call that I wouldn’t be about to attend the simple deliveries even if I wanted too. However, this would not work in the smaller centres. Call shifts take time away from my family, and I want to be compensated for that.
I don’t truly believe that midwives are cheaper care. Hey get paid more per patient than our GPs. When I worked in Ontario, hey got paid better per patient than the OBs, we just saw more patients so we were paid more. However, the low risk maternity provider cannot practice without backup provided by OBs and our nursing and anaesethic colleagues. They may order fewer tests, but they should have the lowest risked patients. When the risk level changes, obstetricians are consulted and we order all the tests. Who your care provider is does not change what care you need, but is many cases wi change the care you receive.b choosing a midwife is not a magically protection from pregnancy complications, nor is wishful thinking or positive thoughts.
Great job, Dr. Amy!
My favorite Dr. Amy line – which was uncontested by the two midwifery zealots:
“When inductions go down, the stillbirth rate goes up.”
That is a terrifying thought. I like my OB because she is so much more than just someone who sees women during the “birthing year”. She also practices urogynocology, can diagnose and treat a host of women’s health issues and is always learning new and more effective surgical techniques. I fear that midwifery led care will have women either having to resort to herbal/homeopathic self care or they will be settling for treating symptoms as opposed to getting diagnosis and treatment ( for example, having a midwife suggest a regimen of evening primrose oil and vitamin D for complaints of cramps as opposed to testing to rule out something like endometriosis)
Yes. This. An OB/gyn can be so much more than a specialist you see when something goes pear-shaped with your pregnancy. My OB/gyn did so much more for me. And still does. I don’t want a midwife. And I thank God regularly that my OB/gyn is such an accomplished surgeon.
In the european country with the best birth outcomes (germany) they do use in hospital midwives for low risk birth, but the gatekeepers are still the obs who do all of the prenatal care and lots of nsts and regular blood and urine teats and ultrasounds. The midwives in the hospital also are required to do continuous fetal monitoring and to call for an ob consult if anything is amiss.
In terms of hand holding and methods, what you get with a hospital midwife here is no different than what you get with an L&D nurse and an OB.
It is only when non evidence based ideas about evil interventions start to infect a practice that the procedures start to vary. This happnens in non-hospital based birth centers which (just like in the US) have triple the perinatal mortality rate compared to hospitals. The hospital keeps this from happening by setting strict protocols and reviewing outcomes.
Britain and the netherlands have the midwives as gatekeepers and they have worse outcomes with less intervention and testing.
What’s funny about the induction argument is that midwives *do* induce – just with castor oil shakes and other dubious woo methods.
Some (obviously not all) don’t have a lot of faith in those methods and will be straight up honest with you about it at least. My wife was a little over one week late, and at her BPP , the radiologist said he suspected the baby was asymmetrical IUGR, and him and the OB agreed we should induce ASAP. The OB was okay with the midwives we were seeing trying with cohosh first, to see if they could get things going, and they were completely honest with us about the chances of it working – they told us it was unlikely to work very well, and would likely end up with my wife dehydrated and being transferred. Final choice was up to us, but everyone involved thought that the OB doing it with pitocin at the hospital was the better choice, and we appreciated the honesty and agreed. It’s a shame that MW’s who are VERY cautious about things, know their limits, and don’t behave foolishly are dragged down by idiots who try giving IM pitocin injections at home and other imbecilic tralala.
Theres no savings once HIE babies are included….
Besides, what does it matter even if HB and NCB was cheaper? We don’t require others to deal with painful things without meds (unless they are addicts/ex addicts, who are treated like slime). why not make people get colonoscapies without sedation? How about heart surgeries with only hypnosis? Why stop there, how about no more marrow transplants, just affirmations?
Some HMOs have tried to refuse coverage for sedation during colonoscopy.
And why not?! After all, in the Good Old Days anesthesia for colonoscopy was never used. And that was even with using the old rigid scopes. Pain itself never kills anybody (as any torturer worth his salt knows).
It can, actually, though there usually has to be an underlying condition. Flip side, how many healthy people are going to be in that degree of pain?
This needs to be said more often. The money spent on maternity buys things of value – reducing women’s pain matters, reducing the likelihood lifelong morbidity or mortality to women and children matters. It is time to quit pretending like pain doesn’t matter, that lives lost at the start don’t matter, and that quality of life after birth doesn’t matter. The economics of this area of care is so poorly done – and vast improvements could be made (like looking at the costs avoided over the lifetime of the woman or child if the investment is made at the critical time). Want to see what being cheap gets you – look at the AIM New Zealand website…..
I agree. maternity care is probably one of the few areas in medicine where the ROI is actually very large.
Depends on what you call ‘cheap’, there’s a huge push for quality care as it’s a public health system and events like preventable wound infections or birth disasters push up costs. It depends what you are looking at, I’ve seen in this thread or another that someone’s aunt had to forgo an epidural because it wasn’t covered in insurance and it cost $1000.00, whereas when I needed an epidural for pain relief, it was offered and I could accept it without worrying about any extra costs direct to me. Also getting maternity coverage full stop seems to be an issue, you can compare there with something like 96% of women getting maternity care before 14 weeks in NZ and they receive those services free of charge to the user. It might not necessarily be an obstetrician that provides that care but even when you see one privately they require that you hire a midwife to provide pre-natal, labour and delivery, and
post-natal care (only 0.01% of births are not attended by an midwife, and that includes historically. In the US, L&D nurses fill that
function). But then we are looking at completely different models of
healthcare, we generally see GP’s as the first point of call also with
specialist care on referral.
Improvements are being made, and constant review as well of the system and whatever failings it has but recently there was $NZ103.5 million put towards quality improvements as well as $NZ40 million extra to cover higher birth rates. There is also an extra $NZ18.2 over four years specifically for maternal mental health
care. I don’t call that cheap at all. I’d suggest looking at the Health Quality & Safety Commission website, the Health Improvement and Innovation sites, AIM does an excellent job, we need advocates and
for them to speak out about any deficits in the system and the effects on real people and their lives but that at the same time isn’t the whole story in regards maternity care and it’s funding in NZ. The latest data looks at least promising, with trends downwards on some critical figures – according to the perinatal mortality report I’m
looking at e.g. the hypoxic peri-partum death-specific intrapartum
stillbirth rate (excluding congenital abnormalities) data says this was 0.26/1000 in 2007 and in 2011 0.07/1000, the intrapartum stillbirth rate (also excluding congenital abnormalities) was 0.16/1000 in 2011 compared with 0.43/1000 in 2007.
I don’t even know why they invited you since it was clear that they were not interested in your opinion. I would rather pay more and have a live baby with no brain damage.
I was getting so frustrated!! They kept cutting off Dr A. What the heck! Even the gal hosting it did.
NCBer “Here’s how to make things cheaper, no interventions, no c-sections, this study xyz is proof this route works well”
Dr A “no actually that study is flawed so it -”
Host “I know childbirth is a sensitive topic so try to stay on topic!”
Repeat 3 times. That was the first 15 minutes or so.
I was listening only and I posted my takeaway on the Fed Up FB page. It was basically “Hey look at how much cheaper birth centers and midwives are. Outcomes are great too. Why don’t we have more of them?”.
Well because first – the outcomes aren’t that great, the single study is applicable to a minority of birth centers and a minority of women. Once you reduce the pool of eligible women down to those who can access a qualified birth center and who are also properly low risk, the economic impact is small.
If we look at the CPM certification, we see that a push to create greater access to midwife care resulted in greater access to poor quality care. A push to open more birth centers is likely to follow that pattern. The birth centers will open in states that have the least regulation and oversight (easier, faster, cheaper) and soon enough there will be a pattern of not risking out properly, not transferring promptly.
IOW, we’ll see more Greenhouse Birth Centers popping up.
“If we look at the CPM certification, we see that a push to create greater access to midwife care resulted in greater access to poor quality care. A push to open more birth centers is likely to follow that pattern. The birth centers will open in states that have the least regulation and oversight (easier, faster, cheaper) and soon enough there will be a pattern of not risking out properly, not transferring promptly.”
Exactly. Also, if birth centers start working with a broader demographic (i.e. not just white, non-smoking, kale-eating yoga-enthusiasts), their outcomes are certain to start looking worse.
Ridiculous how the moderator kept coming back to cost, and cut off Dr. Amy when she wanted to talk about outcomes. Isn’t the outcome kind of the point?
Bureaucrats try to save money. Ob/gyn’s try to save lives. I am so thankful for all the technology that protected my children’s lives and my life too.
Note – this is penny wise and pound foolish thinking. The impact of birth gone wrong is very costly indeed….
The moderator of that debate wasn’t very good at her job.
Yeah, she kept steering the conversation back to cost-cutting, without quite grasping that it all depends what you are getting for your money, so it is essential to discuss if the care is actually equivalent or not.
She seemed really biased, she works cut off Dr Amy before she could refute the crap saying it was OT, while letting the other two morons go on and on and allowing them to interrupt Dr Amy.
You have the patience of a saint Dr Amy. I don’t know how you appear with fools and manage not to lose your sanity.
Off topic, but related to a previous post regarding a home birth disaster and subsequent lawsuit against Johns Hopkins.
http://www.mdcourts.gov/appellate/cosa/2013/1394s12.pdf
Someone else’s summary of the info:
Background- A failed homebirth presented to Hopkins. Baby was eventually delivered by C-section with HIE and cerebal palsy. Jury awarded $55 million, based on claims that Hopkins breached standard of care by delaying the C-section for approximately 2 hours. Excluded from the jury trial was testimony regarding the home birth midwife’s deviations from standard of care and gross negligence, along with the fact that her license had been suspended and she had no collaberating physician.
Now- the verdict has been overturned and the case will return to trial. Read the details here- it makes for a fascinating and horrifying read.
http://www.mdcourts.gov/appellate/cosa/2013/139…
Some interesting bullet points (all info excluded from the trial).
-The midwife let the mother go to 41 weeks and then “induced” her by breaking her water
-midwife ignored her GBS positive status and had her do a hibiclens wash and take probiotics
-midwife gave her IM pitocin THREE TIMES to augment labor, without recording any monitoring of the baby or even documenting dosage.
-midwife tried to deliver baby by applying fundal pressure
-midwife cut an eposiotomy while baby was at +1 station, then sewed it back up when the baby did not deliver and before transport to ER
-mother was uncooperative and combative to staff at Hopkins, refusing to give medical history, refusing to consent to C-section, and refusing blood draw. Fought and moved during blood draw, resulting in insufficient quantity and a re-draw. Mother kept removing monitoring equipment.
“mother was uncooperative and combative to staff at Hopkins, refusing to give medical history, refusing to consent to C-section, and refusing blood draw. Fought and moved during blood draw, resulting in insufficient quantity and a re-draw. Mother kept removing monitoring equipment.”
I read the appellate decision, which didn’t mention these things. Were they in the trial court decision?
Footnote 13.
And again we are back to this old question of mine: should a mother be c-sectioned against her will if she doesn’t “understand the risk”? It certainly seems to me that this birther says ‘I am suing you because you didn’t stop me from being an idiot! You should have known that I was an idiot who was incapable of making decisions so it was your responsibility to magically do that C-section aganst my will. You are to blame and you’ll pay.”
What an impudent woman! Even by the all-natural standards, surely she must be a twit?
I completely agree with you, but I think some people are forced into suing because it’s the only way they can get enough medical care for their injured baby.
Yes, they are forced by practicalities. Yet, this doesn’t make it morally right. Money don’t fall from trees. This pair of idiots damaged their baby and suddenly, it’s right to demand the taxpayers’ money insisting that the hospital was the one who did the damage and they were the victims here?
I still think it despicable. Especially when she was the genius who didn’t consent to the C-section and then howled she was a victim.
For the sake of justice and morality, I wish there was a lawsuit against those pigs of parents for a frivolous lawsuit, non-material damages, and wasting the court’s time. For the sake of the child, I wish that’s the end of it because he needs his parents’ care.
This would be awful and humiliating, but what if the condition of the settlement was that the family did a certain number of public speaking engagements, explaining the importance of hospital care and prompt c-sections? They could get $100,000 per prenatal class visited. (It would take 550 visits to reach $55 million.)
I am not sure I understand your meaning. You mean that the hospital should lose all that money in exchange for a benefit of the general public health? I find it awful and humiliating, and offending… to the hospital. It didn’t do anything but try to help this nitwit who was foisted upon the staff by her butcher of a midwife she’s still defending.
To me, there’s nothing humiliating in working to provide what your child needs. To me, the most humiliating thing is to damage your child with your foolishness and then keep insisting that the people with the big money did it because… well, they are the people with the money. And keep defending the butcher who actually caused the damage.
To me, this pair of idiots lost their dignity when they stopped the hospital from helping their already suffering child. They cannot be humiliated further. To me, the dignified thing is to give your baby a chance.