Does the American health system over medicalise birth?

[Schooldil3ma]

A friend of mine is giving birth in America. She had an easy pregnancy in her country of residence, and arrived in USA at about 32 weeks. Jeez, she has had every test, multiple appointments, it's been almost all consuming. She's now in hospital ready to start labour, again so many interventions, she's been in about 3 days already.

Do you think she's just unlucky, or is the way it goes, especially as she's obviously paying?

@Discovereads

Wrt poor women not able to afford the $10k it costs to have a baby...

States operate their own Medicaid sub sections for pregnant women, and children to age 18.

Any pregnant woman can sign up if income/family size falls within certain federal and state limits. The care provided is exactly what you would get if you had private insurance. You get a private or semi private room and good nursing care. You wear the same hospital gown everyone else wears. You get to bring home the same perineal ice packs and irrigation bottles and free maternity pads everyone else does. If you want advice on breastfeeding the lactation consultant will knock on your door and go over any problems or questions. The hospital social workers will get you connected with any services you could benefit from.

The beauty of a litigious culture is that all doctors can be sued even by patients who don't pay a dime. You don't end up with years long government inquiries into dozens of avoidable deaths and birth injuries.

@RegardingMary nobody sees an OB/Gyn weekly unless it's indicated for medical reasons.

You go every month to midway through the last semester, at which point you might go every two weeks. Once you get to 36/38 weeks you might go weekly to see how you are progressing. Your doctor or midwife might order a non stress test or a stress test as indicated. You will be tested for strep B, a routine test which saves babies from worst case scenarios of sepsis and death but is not routinely done in the UK iirc.

You see a doctor/midwife from the practice you're signed up with at every pre natal visit. They are the HCPs who will be delivering your baby and doing your checkups afterwards until you're discharged and again at 6 weeks. This is regardless of your payment/insurance status.

@mathanxiety yes of course the child will be seen and yes she was well looked after medically she wasn't worried about any issues there but her sister in Ireland had a baby at the same time and while the baby in the US was seeing paediatricians at development checks her sister was popping in to the public health centre in a more relaxed way . As a first time mother she was quite envious of things like weekly drop in weighing clinics etc and as you've said there is zero stigma here about using these services. Now obviously we are taking about a healthy baby and straight forward birth with no issues I'm sure the US system is amazing if any medical issues show up.

Natural childbirth is risky.

C-Sections are much safer option

Why do people write things like this when it’s not true. Both carry risks and it’s about what is appropriate/the least risky for mum and baby.

Absolutely this. I think the midwife system is better overall but clearly you need a back up service of doctors for those women for whom something might or has gone wrong. I had no pain relief for a while but an epidural when I needed it, which seems perfectly sensible. There's a slight risk as it can slow the labour down, so happy not to have it from the beginning, but needed it in the end as very strong contractions and a fairly long labour so just became exhausted.

If I'd found the pain unbearable from the beginning, then it would make sense to have it straight away. The person who said the pain is like toothache is just ridiculous. It might well have been so for her but everyone has a different pain experience, depending on the strength of the contractions, the position of the baby, the way they experience pain, the length of labour etc.

I certainly wouldn't have chosen a CS myself, even despite the pain, unless it was medically indicated, and if it were, or if I had needed it for whatever reason, I'd have been grateful that it was available.

Incidentally, the only women I know who had a stillbirth happened because the staff weren't listening to the concerns of the mother and giving her adequate attention in general, probably because she was a young woman. Also true for the majority of the ones I have read about. If women are listened to then I think stillbirths and maternal deaths would be slashed.

I have given birth three times in the UAE, so not the US, but a similar fully privatised healthcare system.

In my opinion, a lot of things here are over medicalised, simply because someone else is paying and doctors get a kickback in many cases. Take your kid to the GP with a sore throat and they will be swabbed straight away for strep. My husband was found to be anemic, and rather than just being given iron supplements, had a camera down his throat and up his bum, and had to swallow a small camera 'pill' that took photos as it passed through him. Must have cost a lot of money and the upshot was still 'yeah you need to take an iron supplement.'

In terms of OB/GYN care especially, there's actually a real push back on over medicalisation. If you go on Facebook groups for western expat mums, they are full of women asking for OB/GYNs who are known to be 'hands off' or 'take a more UK style approach' - by this they mean, no pushing you to have a c-section for some tenuous reason, no encouraging you to be induced if you go slightly overdue, enabling water births and the use of G&A etc...

FWIW, I had three vaginal deliveries using G&A - nothing out of the ordinary but am still considered some kind of medical marvel/heroic supermum by many of my Arab colleagues.

The key is if income/family size falls within certain federal/state limits
32 million people in the US fall outside these limits and are still unable to afford healthcare. More than half of these 32 million are women.

@mathanxiety

There's a good reason we don't routinely swab for strep B in the UK.
Strep B is transient, you can be positive Monday but negative Thursday and remain symptomless for the entirety, so swabbing only shows you what is happening at that present time.
If you have any vaginal swabs through pregnancy they add on a strep B test but wouldn't swab separately, as I they did loads of women would be given antibiotics in labour that simply don't need them.

I’d say yes.
A friend of mine lives in Ohio and I was stunned when she showed me a screenshot of her itemised medical bill 😳
We had our second babies within a week of each other, both had pretty straightforward, uncomplicated pregnancies and births. She’d seen her obstetrician almost weekly towards the end, a plethora of tests, way more ultrasounds etc.
I barely saw my midwife - maybe 5 appointments in total. Had my usual 12 and 20 weeks scans, plus a couple of growth scans because there were concerns about him being small. As for the birth, it couldn’t have been simpler. I gave birth on my living room floor, with a very “hands off” nhs midwife who was only really there in case of emergency. She was happy to just leave me to get on with it - which is what I wanted. No poking, prodding, monitoring, examinations etc.
The difference between our experiences are stark. And I’ll never forget my friend saying to me “The US healthcare system can’t make money off of healthy mothers and babies” 👀👀

I think the UK system (if properly staffed) is better. I prefer having a midwife with back up available from doctors in event of complications.
In the US women often have less choice and fewer rights - it's even more paternalistic than here.

As evidenced by this thread some women want epidurals but not everyone does. I don't want one as find idea scary and I found childbirth pain bearable. The focus should be what is right for each individual woman.

The NHS can do loads of testing and hands on IF ITS NEEDED but the point is for most it's really not needed.
I had a high risk pregnancy (I have a chronic condition/disability) and had loads of testing, scans, regular consultant and midwife and physio appointments
I suspect for those with the right insurance birth in the US is a fairly ok experience however lots of testing and intervention doesn't always make for a 'good' experience as it can ramp up the anxiety levels for patients. I know you'd expect it to reassure but actually it does the opposite as people are on high alert that something is wrong or we can 'over treat' which means unnecessary drugs or investigations.
For some people this is good because things are spotted but for some it just stresses them out and for the majority it's just not needed.
The U.K. is by no means a perfect system but it does when it has adequate staffing (not at the moment) have a fairly sensible approach to treatment.
I suspect all countries systems could be better in some way.

Some of that will be down to maternal choice though. I gave birth in a private system with an extremely relaxed Dr (I chose her because she has a reputation for not pushing interventions). My second was due 23rd December so I opted for a due date induction to avoid a baby born Christmas Day. As it happened he was induced early for medical reasons. I chose to have the epidural and drip straight from the start as I didn't want to drag the process our for days on end and didn't want to be in pain. I don't doubt that some doctors do push unnecessary interventions but some of it will be maternal choice.

Totally agree!

@wonkylegs, if you haven't given birth in the US yourself, then you really don't know what you're talking about.

Testing isn't done randomly or for no reason. Testing is not intrusive or time consuming. Insurance companies and the medical profession alike have found over millions of patient outcomes that certain tests increase the chances of good outcomes.

Testing doesn't add to stress or generate it. A blood test at the initial visit to detect issues including drug use, rhesus factor, etc, pap smear at initial visit, peeing in a cup at each monthly visit for protein testing, testing for gestational diabetes at the 24 week stage (iirc) so that GD can be caught and controlled, testing for strep B so it can be treated before it causes problems for the baby, non stress tests in the final weeks are all necessary, as is an ultrasound to confirm dates and one later (at around 24 weeks iirc), with another to check for neural tube issues and Downs syndrome if indicated. You can turn down amniocentesis and opt for a more detailed ultrasound or nothing at all.

Most women would rather know if there's a problem, and deal with it. The alternative is hiding your head in a bucket and crossing your fingers..

And the exact same standard of care is given to all pregnant women regardless of insurance status, public or private.

The assumptions British people have about the US say a lot about Britain and British experiences and expectations.

@GreenRainbowSun

Nobody in the US is forced to avail of any testing or any anesthesia options or procedures during delivery.

I turned down an epidural three times. I had only one in five deliveries, my first. At the second one I wanted an epidural but the anesthesiologist was stuck in theatre and couldn't get to me in time. He arrived in the delivery room as the nurse was weighing DS and applogised profusely. The next three times I had -
1 no time, baby arrived 45 minutes after we got to the hospital
2 decided to skip it
3 decided to skip it

Every time a procedure or intervention is suggested the patient can refuse.

@RegardingMary, take a look at the sepsis /meningitis figures for the UK.

The problem is caused by untreated strep B. There is absolutely no good reason not to swab specifically and to treat prophylactically.

Which is the worse outcome, a brain damaged or dead baby or a course of unnecessary antibiotics?

@mathanxiety you are assuming I have no experience of the US health system. Yes I personally haven't given birth there however we have a lot of close family, friends and colleagues who live, have had medical care and work in the US medical community (they are doctors) and it is a subject that we have discussed a lot as DH is a dr and has been offered several jobs there. They are based all across the US but mostly in California, New York ,Texas, Mississippi and Florida so a mix of experience.
It's an issue that doesn't affect all but is well known and discussed topic that affects all sectors of health care not just maternity health.
Some testing/procedures can be good and I don't argue against it however it's not always as necessary and other courses of action can be more appropriate.
I know you will dismiss my experience because it doesn't tally with yours however the AMA (American medical association) also see it as an issue www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/ and Harvard
www.health.harvard.edu/blog/is-our-healthcare-system-broken-202107132542
And the NYtimes www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html

utswmed.org/medblog/pregnancy-questions-obgyn-doctor/

There are several other articles and studies on the subject but citing the conclusion from the first one regarding the AMA study "from the physician perspective over treatment is common" makes my point just fine.

The nih.gov article did not include OB/Gyns in the survey.

The NYT article is from 2013, before the ACA changed the overall insurance market significantly.

The advice from the doctor in the med blog has always been the case. Ask why, ask for statistics, ask for justification of procedures, ask how the test will change care depending on outcome.

www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Percentage of pre natal care and births paid for by Medicaid, by state.

www.theguardian.com/society/2022/mar/30/as-an-nhs-midwife-the-shrewsbury-baby-deaths-report-didnt-surprise-me
This is a jaw dropping account of chronic, unaddressed under-staffing, ignoring of patients, plus failure to work with other teams.

www.theguardian.com/society/2022/may/26/shropshire-baby-deaths-inquiry-midwife-donna-ockenden-lead-nottingham-review
This is astonishing too, given the publicity around the Shrewsbury cases:
The Care Quality Commission (CQC) published details of unannounced inspections it carried out at the trust in March. It said overall maternity services at the two sites remained inadequate and issued the warning notice, with the potential to use enforcement action, in relation to how the trust is managing observations of women, with basic checks not being carried out that would tell if a female patient was deteriorating...

...The CQC concluded that while staff tried to provide good care, “the service did not have enough staff to care for women and keep them safe. Not all staff had training in key skills.

“Staff did not always assess all risks to women, and we were not assured staff acted upon concerns in a timely way.”

Across the sites, inspectors found staff did not always keep good care records and did not always manage medicines well. They also did not feel assured that staff reported all incidents and near misses, and workers did not always receive feedback.

www.bbc.com/news/uk-england-kent-51439593
This is all really, really bad. (East Kent).

It's not all low staffing, even though there are heavy hints that there are not enough staff in maternity units. Clearly there are some NHS trusts which have enough staff. And in the case of Shrewsbury, insufficient staffing over so long - if that is claimed to be part of what went so wrong - is a problem which really should have been addressed.

Maybe there's a happy medium? I think that point lies more than half way across the Atlantic personally. Maybe about 7/8 of the way across.

My late FIL was a surgeon, and a BIL is also a doctor. DS will be out of medical school in a year and hopefully into the residency he has his heart set on. There is a lot that should be changed in US medicine, but testing isn't the big problem to start on.