New Wellness Paradigm

Introduction

A New Wellness Paradigm for Birth in the United States

Welcome to parenthood! My mission is for you to have a happy healthy pregnancy and a beautiful baby for you are about to embark on life’s greatest satisfaction. This is your road map to have the best pregnancy experience possible. While the twentieth century witnessed dramatic declines in maternal and infant mortality as a result of improved medical care, the twenty-first century presents novel challenges and opportunities. Some of these derive from within ourselves and we can exert complete control over them; while others arise from external forces. The three factors that will have the greatest impact on our health this century are lifestyle, finances, and technology.

I have delivered babies and cared for people for fifteen years and through the years I have learned we exert the greatest control over our health through our lifestyle. Here I define lifestyle as our work habits, eating habits, and exercise habits. Most illnesses are brought on by a chronically unhealthy lifestyle. It’s those little decisions we make day-to-day that pile up over time and cause us to enjoy good health or suffer bad health: whether or not to work those two hours of overtime, what to choose for lunch from the cafeteria, whether or not to exercise that day.

Lifestyle

My desire to impart to you an insider’s understanding of pregnancy and birth so you can take charge of your health engendered DIY Baby! (Do It Yourself Baby!). Pregnancy is a physically stressed state for the body. It’s a normal state, but it does test our physical limits which is why most pregnancy-related illness are a manifestation of or a first sign of common medical conditions such as diabetes, high blood pressure, and consequences of stress.

Over-eating causes diabetes and high blood pressure in the pregnant and non-pregnant state. It increases the risk of pre-eclampsia (high blood pressure), gestational diabetes, cesarean section, dysfunctional labor, infection, and heart disease. Over-work and stress cause preterm labor, high blood pressure, heart disease, anxiety, and depression, including post-partum depression. Inactivity exacerbates the ramifications of over-eating and over-work.

Finance

Health care expenditure occupies the largest portion of the gross domestic product. In itself there is nothing wrong with this as we are nothing without our health. However, it’s out of control on many levels such that more frequently our health care decisions are being determined by finances. As of this writing there are nearly 45 million Americans who lack health insurance. Many people with insurance have “high deductible” plans and bear a greater percentage of the cost of medical care out of pocket. Many insurance plans excluded maternity and contraceptive coverage or require payment of extra premium to obtain such coverage.

Even uninsured American citizens are paying for our healthcare system via any of three avenues: through state and federal income taxes to finance Medicare and Medicaid programs; through “cost shifting” – the subconscious practice of raising prices to offset losses incurred by the uninsured; and directly through rising health care premiums, or losses of benefits or jobs due to rising health care premiums. The middle class American citizen also pays a huge percentage of their health care dollar to fatten the coffers of the “middle man”: the insurance carrier. During the late nineties and early 2000’s we’ve witness CEO’s of insurance companies take home multi-million dollar pay packages while we watch our premiums jump double digits from year to year.

Illegal immigration has “snuck up” on us in the past decade to the point where it pressures the health care system to the “breaking point”. Many recipients of Medicaid in the State of Colorado are illegal immigrants who receive Medicaid “Emergency Services Only” (ESO) benefits to deliver their babies. When I began private practice in 1996 illegals constituted about thirty-five percent of the deliveries at the hospital at which I deliver babies. As of the end of 2006 they represented nearly seventy percent. Medicaid “ESO” reimburses physicians roughly twenty cents on the dollar. The average physician office overhead is fifty percent so I pay thirty cents on the dollar for every Medicaid ESO patient I deliver. This is simply unsustainable.

If you think the impact of illegal immigration has been minor, think again: In 2006 nearly seventy percent of babies born in California were to illegal immigrant mothers. This resulted in the closure of many smaller obstetric wards in the state. At Parkland Hospital in Texas the rate of births to illegals soared to the high eightieth percentile over the same time period. The early 2000’s witnessed closure of twenty-five percent of obstetric wards in the Philadelphia metropolitan area due to declining reimbursement and increased cost of malpractice insurance for hospitals.

This does not mean I advocate denying illegal immigrants access to healthcare or some other racist hogwash. However, they should have to bear the same financial burden as the rest of us middle class Americans to enjoy the benefits they receive. I simply ask they pay their way as we all do.

Figures from the American College of Obstetrics and Gynecology (ACOG), the national organization of women’s health care specialists, revealed that in 2006 seven percent of ob-gyns ceased offering obstetrics altogether and another twelve percent reduced their practice to accept only “low risk” patients. This represents a nineteen percent reduction in obstetric services in a single year. Obstetricians cited three major factors for reducing or eliminating their deliveries: declining reimbursement, stress and cost of malpractice issues, and lifestyle.

Obstetricians are not being replaced at the rate they are leaving the field. For several years in the late nineties and early 2000’s obstetric residency programs were under-filled, at times reaching as low as a sixty percent fill rate with American medical school graduates. The remaining slots in those years were offered to graduates of foreign medical schools. Some of these U.S. trained foreigners remained in the United States; but many returned to their native countries to practice.

Technology

Now is the best time in history to bear a baby in the developed world. Mortality rates of mothers and term infants are very low. The hospital “Maternity Ward” has evolved into the “Family Birth Place”. The homey LDR (Labor, Delivery, and Recovery Room) has replaced the sterile “closet” tiled in puce where women labored on gurneys and were transported to an operating room to deliver strapped in stirrups with their legs in the air.

A paradigm shift has occurred in the mentalities of obstetric care providers and labor nurses. The paternalistic patient-doctor or patient-nurse model has been replaced and providers now view themselves as expert support personnel. They see their role as the imperative to create as safe, individualized and fulfilling a birth experience as possible for everyone who walks through their doors. Women and families are more empowered in their birth experience than they were fifty or even twenty years ago. They possess greater information about their options and are savvier.

We’ve spent enormous resources and training to make hospital delivery as much “like home” as possible with the safety net of proximity to emergency services. However, while some obstetric emergencies are indeed unpredictable, most are predictable based on easily identifiable risk factors. The truly dire emergencies such as cord accidents and massive placental separation have an incidence of slightly less than 1/1000 births and cannot be prevented and may not always be “rescued” by delivering in a hospital. Even if the baby is “physically” saved in such a situation, he may suffer irrecoverable mental damage and live out a short one-to-two year life in a vegetative state hooked up to machines.

Many obstetrical “emergencies” are actually “urgencies” which can be mitigated by changes in labor position or administering medication to stop labor and other conservative measures. Fetuses endure a great deal of stress during labor and they have an enormous capacity for recovery and regeneration. We’ve learned the brain is more capable of growth than we previously thought and we prevail intact not only because of but despite our efforts
technology, which has been our greatest friend in the past century, is becoming one of our worst detractors. Ninety percent of the health care dollar is spent on the last six months of life; and a significant portion of the remaining ten percent is spent on permanently impaired premature babies. The 1996 cost of babies born between 25 to 36 weeks gestation rang up at $38,000,000. Present estimates put that figure at $2,000,000,000. We’re spending enormous resources on the extremes of life.

Despite the technological advances made in medicine in general we have not been able to lower the U.S. preterm birth rate. It has remained about ten percent for the past fifty years and has climbed slightly during that period. I posit this as attributable in part to our stressful lifestyle in addition to socioeconomic and medical factors.

A phenomenon which I’ll call the “medicalization” of life and death has seeped into our culture over the past century. In the past we used to die and were born in the home; we were cared for by relatives in the comfort and security of a familiar environment. Now we die and are born in hospitals. We are kept alive, often in a “vegetative” state at either end by machines connected to our bodies through tubes and wires. I ask is this the best way? How much value should we place on the quality versus quantity of life? When and how do we draw the line for a cost-benefit analysis? What other ways are there to be born and die? Is there a sweeter way?

DIY Baby!

Do It Yourself Baby! is not a missive for you to go out and have your baby in the back yard. It is intended to avail you of the tools to maximize your wellness through the factors you can control and make the best of those you cannot control. Knowledge is power and the more you know about pregnancy and birth, the healthier you will be throughout life. I offer you a new wellness paradigm to approach your pregnancy in a pro-active fashion. Assume responsibility for the health of yourself and your baby no matter where you plan to deliver. In DIY Baby! I explore the option of home birth. Is it time to reconsider how we enter the world in this country? Can a select portion of the population safely deliver at home? Should they? What are the logistics? What are the selection criteria? What are the advantages and disadvantages?

Pregnancy can be a time of uncertainty and it doesn’t help that all your friends and relatives feel compelled to divulge their worst horror story of their pregnancy, labor or delivery. Despite the availability of resources on the market my patients’ questions have made me realize the existing materials are not conveying the information in a manner that’s readable or stays with you.

I hope this guide will give you, in a short time, a practical overview of what to expect from pregnancy and delivery. I wish to assuage your worries, as most of you will have normal vaginal deliveries. You will gain an obstetrician and mother’s perspective and knowledge of pregnancy and birth.

If you’re going to be a new dad, I hope to provide a guide to the changes in your wife’s body, as well as a road map to how to navigate her hormonal and emotional changes; and your own changes in adapting to fatherhood.

For the scientifically curious I include some of the medical background information on why you are experiencing the symptoms you are.

Above all I want this guide to give you a sense of confidence and empowerment when it comes to your pregnancy and birth. I hope you enjoy the ride and above all, happy new baby!