A Glimpse of Consumer-Centered Healthcare

I almost had my baby in a car.

Fortunately, I didn’t, but what I learned from the experience helped me to see how the healthcare system isn’t working for consumers and could be better.In Labor and in the Car

It’s hard to overstate the discomfort of giving birth, even in the best of circumstances. But when your enormous, pregnant midsection is strapped into a bucket seat by a seatbelt, you can’t move the way your body demands to manage the pain and get the job done. While I’d labored for hours pushing out my first child, it was just as much work to keep my second one from barreling right out in the front seat of the car.

My pain was intensified by fear. What if something went wrong with the birth? What if we got in a traffic accident? What about the germs, the blood, the carpet?

When my husband (the driver) pulled up at the hospital, I hastily made my way to the nearest available bed and let that baby out, to the utter surprise of a medical technician who was working in the room on a computer. The technician — the only hospital staff to witness the event — was later recorded as having “delivered” the baby. If anyone can be said to have delivered my daughter Ada, I’d say Ada did it herself, with more than a little help from Mom.

Next, My Obstetrician Fired My Doula

An obstetrician is a clinically trained birth doctor; for me, his services were covered by my health insurance. A doula is a birth coach trained in holistic health and her (significantly less expensive) services were covered by me, out of pocket.

People in the two roles can work independently, or together. I hired the doula on my own, with the agreement of the obstetrician. The obstetrician was to deliver the baby and the doula was to help prepare and guide me through the end of pregnancy and labor in a way that met my personal goals and that supported me physically and emotionally in the context of birth.

Though I was at first oblivious to the secondary drama unfolding around me, after the birth, my obstetrician was furious. He refused to collaborate with the doula ever again, blaming her for encouraging me and my husband to wait until the last minute to go to the hospital.

The Clash Between Consumer and Health System Preferences

To an extent, I appreciate where the obstetrician was coming from in refusing to work with the doula. Car birth is risky. The doula had indeed encouraged me to labor at home as long as possible, playing word games with me and my husband until my contractions got so intense I couldn’t find any more words.

The complicated part is that the doula was doing her best to meet the goals I’d set out, which included avoiding medical interventions to the greatest extent possible, and, at the same time, giving birth inside of a traditional hospital in case of any emergency needs.

Small interventions often cascade into major ones. For example, if you have monitors tethering your body to a bed, you are less likely to be able to ease the baby out through movement and gravity on your own, so you may need an induction, which, in turn may precipitate other interventions.

The Reality of Being a “Health Consumer” Today

It is depressing to me that my doula, in trying to respect my wishes as a patient, felt compelled to keep me physically out of the hospital to do so. It is infuriating that most women (and men) lack a clear understanding of the medicalization of birth and the lack of consistent, evidence-based practices.

For instance, Consumer Reports warns that the likelihood of having a C-section can be as much as 9 times higher if you pick the wrong hospital. Nearly one third of births in the U.S. are C-sections, according to the Centers for Disease Control and Prevention. To put it bluntly, there is a great financial incentive for hospitals and healthcare providers to perform C-sections. The costs, in both health and dollars, are picked up by someone else, mostly the oblivious consumer.

C-sections can be lifesaving, when necessary, but that’s no excuse to overuse them. And if you’re going to offer me the choice of having an epidural, don’t just promise to “make the pain go away”… tell me the benefits and risks, using numbers, please. I’m not really making a choice if you ask me to make it without knowing the facts.

Sadly, the lack of transparency for patients, including the hidden financial agendas of the health system, are not limited to the context of labor and the delivery — most health consumers face the same frustrating and dangerous circumstances most of the time.

How We Can Do Better

Clearly, the predominant fee-for-service financial model in the U.S. is a core part of the problem with today’s healthcare system, setting up conditions that put consumers’ bodies and bank accounts at risk. I wonder if my obstetrician was upset in part because he was unable to bill for delivering my baby, not to mention any potential interventions? To a point, I can’t blame him for trying to make a living. Like all of us, he’s trapped in a system that doesn’t support the best, healthiest outcome for the patient, which I believe is what he, the doula and I all wanted.

In addition to aligning payment models toward value-based care (a process that is underway, albeit not as quickly as I’d like), it would also be wonderful to have a guide for every significant health journey. Someone who asks the patient and family about their goals right out of the gate, and then educates and nudges them toward appropriate options based on facts and preferences. Someone who provides empathetic “whole person” support, including non-addictive ways to manage pain.

In my perfect world, someone like a doula would work in close partnership with a clinically trained medical team, supported by technology, scientific evidence and informal caregivers such as friends or family members to give care consistent with our personal preferences.

I hope my daughter Ada, if she ever gives birth, will have a smoother ride — but that hers will not so prominently feature a car.

This article is cross-posted on the HIMSS19 website and on the Carium blog.