Ever Since I Had My Baby

by Roger Goldberg

  WISDOM—OR WARNINGS—FROM THE MEDITERRANEAN

  In Italy, the law protects each woman’s right to choose between vaginal and cesarean delivery. Over the past two decades, cesarean rates have drastically increased to at least 33 percent, among the highest in Europe. Rates are highest in private hospitals where the technology is more readily available, and they also vary widely by region, indicating that a culture of cesarean delivery has evolved within certain areas. Are Italian women enjoying a personal choice to which they’re entitled, or does their experience reflect a misallocation of resources that other countries should avoid? The issues are complex, and simple answers are hard to find, but understanding the experiences of other countries and cultures may help us make better decisions of our own.

  Economics: The Bottom Line of Labor and Delivery

  Once upon a time—right up until the 1980s—medicine was a fee-for-service profession. Like all other surgeons, obstetricians were paid for nearly every procedure they performed; and cesarean delivery was recognized by physicians as one that was particularly safe, convenient, quick, and also profitable. There were few built-in incentives—cultural, economic, legal, or otherwise—for doctors to push for vaginal births. To no one’s great surprise, cesarean rates skyrocketed from roughly 5 percent in the 1960s to rates exceeding 22 percent in the United States and Canada today.

  Health-care economics still influence the way babies are delivered in the industrialized world, though many of the basic trends have reversed. Along with the emergence of cost-conscious managed-health-care plans such as the HMO, cesarean delivery began to appear awfully expensive at the bottom line of the accountant’s ledger, with its steep operating-room charges and longer hospital stays. Obstetrical statistics became powerful bargaining chips among physicians, hospitals, and insurance providers, with the new emphasis on reducing the number of cesarean births. The validity of these new-age cost calculations have been met with their share of criticism; some experts argue that crucial costs, such as that of time spent on the labor floor, are regularly left out of the analysis. One study, recently presented at the American College of Obstetricians and Gynecologists’ annual scientific meeting, calculated that the per-patient cost of elective cesarean delivery was only 2.3 percent higher than that of attempted vaginal delivery. The high costs of nursing in the labor room, and of failed vaginal delivery, appeared to account for the overall cost of the two strategies being nearly equal. Nevertheless, departments and hospitals began to receive praise for maintaining target rates of vaginal delivery in nearly any form—spontaneous, forceps and vacuum-assisted, even vaginal births after cesarean. Enormous insurance contracts could, for some institutions, be jeopardized by cesarean rates exceeding the target; some went so far as to prohibit their physicians from presenting alternative treatments viewed as less cost-effective. Merely discussing the alternative of elective cesarean with patients would violate company code and, in some instances, put the physician’s job in jeopardy.

  Although gag rules are no longer legally permitted, insurance coverage may still have an influence that reaches—directly or indirectly—into the labor room. One Harvard study showed that mothers with private, fee-for-service insurance had higher cesarean rates than mothers covered by HMO plans and also those who were uninsured. An Australian study of one hundred and seventy thousand women showed that privately insured women were more likely than those with government insurance to undergo cesarean, forceps delivery, and episiotomy. In Chile, privately insured women had cesarean rates of 59 percent compared to 28 percent for those who were publicly insured. In the Campania region of Italy, the cesarean rate in private birthing units exceeded 55 percent, a rate 1.3 times higher than that of public facilities in the same area. Determining the overall pros and cons of these trends throughout the world is a complicated puzzle.

  Our economic understanding of women’s reproductive health, and the cost-effectiveness of various childbirth strategies, cannot be considered complete until the postreproductive conditions we’ve discussed are included in the financial formulas. These gynecologic problems of incontinence, prolapse, and pelvic-floor dysfunction cannot be rationally separated, medically or economically, from their potential obstetrical causes. Put more simply: even if promoting vaginal delivery shrinks short-term costs, the same strategy may increase the number of pelvic-floor disorders we’ll pay for over the long run—creating financial, physical, and emotional costs that may far exceed the initial savings. According to a 1997 study based on the National Hospital Discharge Survey database and average Medicare reimbursements, the direct costs of pelvic-prolapse surgery that year were $1 billion. As the authors of the study emphasized, that figure did not even include the costs of evaluation, diagnostic testing, and office therapies; the indirect costs, such as lost work time and child care; or the millions spent each year on absorbent products.

  As a fuller understanding of pelvic-floor disorders emerges, and their impact on a rapidly expanding postreproductive female population is appreciated, the links between childbirth events and postreproductive health—indeed, the bridge between obstetrics and gynecology—will become clearer. With that transition in women’s health, the economic bottom line of labor and delivery will be calculated not only according to costs incurred in the maternity suite but also according to those that can accumulate during the postreproductive years. Indeed, we’re learning that the true costs of childbirth must be viewed with a wide lens over a woman’s lifetime. Regardless of future financial calculations and miscalculations, fads and trends, only one bottom line is sure to indefinitely persist: the ways we choose to experience the miracle of childbirth will never boil down to economic formulae alone.

  Politics, Policies, and Personalities

  You will find, as a general rule, that the constitutions and the habits of a people follow the nature of the land where they live.

  —Hippocrates

  Just like the foods you choose to eat and the car you decide to drive, your perceptions of childbirth are filtered through multiple layers of your surroundings—family, friends, culture, marketing, advertising, and even politics.

  YOUR GOVERNMENT

  Politics and policies certainly may influence obstetrical culture and practice, though their presence is not always apparent on the surface of society. Consider, for instance, the landmark Healthy People 2000 program supported by the World Health Organization and the Department of Health and Human Services. Among its many stated goals, one was to reduce the nationwide cesarean delivery rate from over 20 percent to a target of 15 percent by the year 2000—in order to spare resources and reduce unnecessary intervention. Replacing cesareans would be more assisted deliveries (forceps or vacuum) and more vaginal deliveries among women with prior cesareans. This is a goal that was well intentioned but not free of controversy. Perhaps most vocally, the notion of a blanket policy to reduce this cesarean rate drew public criticism from several leaders in obstetrics, who viewed the plan’s stated goals as paternalistic, authoritarian, and too strongly driven by economic forces rather than the well-being of mothers and babies. More research into the safety of the program, and a look at its true costs, would be needed before concluding an optimal cesarean rate, according to Dr. Benjamin Sachs of Harvard University Medical School. Even if further research proves that cesarean rates can be reduced to this level without detrimental effects on newborns, the question remains: what about their moms? As Healthy People 2000 evolved into its current form, Healthy People 2010, the target cesarean rate of 15 percent has not been reached, but the policy continues to have an impact. Bolstered by the Healthy People goals, the performance and quality of physicians and even hospitals is often judged, for better or worse, largely around one loaded question: “What’s your cesarean rate?”

  YOUR PART OF THE GLOBE

  Childbirth is an interesting mirror of society all around the globe, and what may be state-of-the-art in your corner of the world may raise questions elsewhere. Consider affluent areas in the
United States, for instance, where women and their partners often go to great length to achieve a natural childbirth experience; then compare these trends to Latin America, where the wealthiest countries have some of the highest rates of cesarean birth in the world. Over the past thirty years in Brazil, the cesarean delivery rate in certain communities has skyrocketed from around 20 percent to over 80 percent. Within this culture that places great emphasis on sexuality and aesthetics, cesareans are viewed as less traumatic to the mother’s genitalia, even a status symbol. For a variety of reasons, including patient pressure for cesareans on demand, physicians have become less inclined to wait through a full labor and delivery. It’s a trend that Brazil’s own health minister recently described as “barbarous,” and one the government has itself recently begun discouraging by offering incentives for vaginal birth. The experience in Brazil represents an extreme by any measure. But clearly, in all corners of the world, the way we have babies is determined by far more than medical science alone.

  THE MEDIA

  Alas, the most global and powerful filter of modern life: the media. Always portraying a story that we’d love to believe, but one that never quite fits our reality. For instance, on daytime soaps and prime-time melodramas, television and Hollywood perpetuate an image of the glowing parturient puffing through the final push, the story always ending with a baby’s cry.

  Or how about those commercial breaks during which millions of dollars are spent on advertisements for absorbent products, portraying menopausal women as attractive, content, and comfortable while wearing pads and diapers on the tennis court, the beach, and at work—leaving you to wonder, “What drug are they really on?” After all, for most women, pads and diapers are not an acceptable solution over the long run.

  Perhaps most confusing of all, the Internet. Filled with sites and chat rooms disparaging any type of medical intervention during childbirth, and others at the opposite extreme indiscriminately mocking the notion of natural birth, it’s a realm that’s overdosed with politics and often underdosed with reliable facts. In a world teeming with targeted marketing, and a cyberspace rich with electronic pulpits for anyone with an opinion to preach from, it’s important to realize how deeply some of these words and images can permeate your consciousness. Sometimes they can even get in the way of good old common sense.

  A Few Golden Rules for the Postreproductive Woman

  If you’re a boomer or younger mom who was convinced that “those problems” your mother dealt with are still inevitable milestones of womanhood, I hope this book has convinced you otherwise, and that any knowledge you’ve gained will help you to navigate the road to better health. As the science, surgery, and medicine surrounding postreproductive problems continues to rapidly expand, keep a few pearls of advice in mind and you’ll do just fine.

  RULE #1: POSTREPRODUCTIVE PROBLEMS MAY BE COMMON, BUT THEY’RE NOT NORMAL OR INEVITABLE

  For better or worse, female prolapse and incontinence have yet to attract a spokesperson as mainstream as Bob Dole for Viagra. One wonders, if curing female pelvic-floor disorders were as profitable as stomping out male impotence, how quickly these issues would emerge from the shadows into the mainstream medical agenda. Make no mistake: female pelvic, bladder, bowel, and sexual function are no less important to your overall wellness than erectile dysfunction is to your male counterpart’s—and perhaps no more inevitable. By now you’ve learned about countless ways to find relief, ranging from exercise, diet, and medications to nearly incision-free surgery, magnetic energy waves, and pelvic pacemakers. If your symptoms are making your life feel less full, there will be no blue-ribbon prize for suffering in silence. Be sure to seek help, in some form or another.

  RULE #2: DON’T GIVE UP UNTIL YOU FIND RELIEF

  With rare exception, there’s always another treatment out there for you to try. Postreproductive women’s health and urogynecology are works in progress, rapidly expanding with a steady stream of innovations coming down the pike. Even if you gave up in the past after finding no relief, check back with a specialist. Very likely, there will be something new for ameliorating, preventing, or at least coping with the major changes that can follow childbirth. Be persistent, remain your own best advocate, and don’t give up until you find relief.

  RULE #3: STAY INFORMED

  Women these days are barraged with facts and figures concerning the hottest health topics, like hormone replacement, osteoporosis, breast cancer, and heart disease. There seems to be a never-ending supply of latest studies on these problems and their prevention, many headlined in mainstream newspapers and magazines. There is also much to keep abreast of on the less mainstream female conditions. Stay informed, and keep giving these areas of your body the attention they deserve.

  RULE #4: ELECTIVE SURGERY IS ELECTIVE!

  We’re fortunate to live in an age when surgical procedures have become less invasive and more effective than ever before. But even if you’ve found the most skilled surgical hands in the world, a decision to enter the operating room should never be taken lightly. After all, there will never be a surgical procedure that can guarantee a perfect cure, and there will always be the small risk of an unforeseen complication or a rockier postoperative road than you expected. If you’re more uncomfortable with the potential aftereffects of elective surgery than remaining in your current situation, you don’t need to have it!

  A Few Golden Rules for the Woman Looking Ahead to Childbirth

  For the younger woman looking ahead to the wonders of pregnancy, labor, and delivery—whatever politics, personalities, and emotions surround your childbirth planning—remember a few basic rules, and don’t forget that you’re the star player of an eternal drama on a stage that belongs to you.

  RULE #1: YOUR BODY ALWAYS MATTERS … EVEN DURING CHILDBIRTH

  Bringing a newborn safely into the world will always take highest priority, at any stage of pregnancy and childbirth. By sheer instinct, we’d gladly sacrifice our own comfort for that of our baby, such is the profound transition to the awesome role of parent. But it’s time to incorporate into the planning for pregnancy, labor, and delivery some discussion of how your body might feel and function afterward. Rather than viewing childbirth as an inevitable physical sacrifice, think of it as an opportunity to experience one of life’s most profoundly beautiful events, while gaining a better understanding of your body and planning ahead for many years of your own health, control, and intimacy. Promoting health in the most intimate areas of your body, maintaining control over your most basic bodily functions, and preserving your sense of youth and sexuality—these goals deserve a place in your health planning. Your one and only body does matter during childbirth, and for a long lifetime afterward.

  RULE #2: MAKE INDIVIDUALIZED CHILDBIRTH CHOICES

  Each pregnancy has its own fingerprint created by a unique mom and newborn, making each and every labor and delivery a completely unique event. As a result, blanket obstetrical strategies will, in the end, be to the detriment of some. Although every birth is a miracle, on a physical level, they’re not all equal. In some cases, a prolonged labor, a forceps extraction, or an extensive perineal injury during vaginal birth may be more physically traumatic for both mother and baby than a cesarean section. For others, the opposite will be true. Unfortunately, the conventional wisdom characterizing vaginal delivery as better in almost any circumstance may be more a product of politics, economics, and culture than of the medical realities of childbirth. Don’t let politics and other people’s beliefs dictate the way in which you and your doctor decide to proceed.

  RULE #3: BE FLEXIBLE, LIKE A WEDDING PLANNER

  It’s wonderful when labor is picture-perfect, but sometimes it’s not meant to be, and the best-laid plans can require some quick reshuffling. So prepare as you wish, and hope for the best, then let go. As with your wedding day, if it starts to rain on the ceremony, be sure to have the physical and emotional flexibility to change your plan. Rainy weddings, after all, can produce some of the most be
autiful marriages. By this stage, you should trust your doctor’s or midwife’s outlook on the whole journey; if the road begins to suddenly change before your eyes, take your hands off the wheel and allow them to drive. Rest assured, it will still be a wonderful day.

  RULE #4: NEVER, EVER SKIMP ON SAFETY

  Whether you’ve chosen delivery by a doctor or midwife, at a hospital, birthing center, or home, put safety first. Align yourself with a provider who is either capable of managing a labor that becomes complicated, or able to quickly transfer responsibility to a backup provider. When labor complications occur, they often strike in a quick and devastating way, and the priorities and mood in a labor room can shift in a matter of moments. There are plenty of practitioners—whether obstetricians, midwives, or family doctors—who can keep the priorities of childbirth clear and provide a safe version of the birthing experience you’re seeking. Again, like a wedding, childbirth can be simultaneously fun to plan, wonderful to experience, and kept in perspective.