Problems With U.S. Maternity Care System

By OBOS Pregnancy & Birth Contributors | April 4, 2014

All women deserve maternity care that is consistent with the best available research on safety and effectiveness and that supports the natural processes of pregnancy and birth. Unfortunately, too often women don’t receive such care.

The U.S. maternity care system frequently offers fragmented, impersonal care that does not reflect what research has shown for decades produces the best health outcomes for mothers and babies. Maternity care in the United States is characterized by several problems:

Too few women get adequate prenatal care.

In the past decade or so, care options—such as testing for pregnancy complications or pain relief options in labor—have become much more complex. Fewer women are taking prenatal education classes and more women are experiencing high-risk or complicated pregnancies. Yet the total time a woman spends in prenatal visits has been reduced. The typical woman may have as little as two hours of interaction with her doctor or midwife during her entire pregnancy.

Too many women are exposed to the risks of high-tech procedures, even when they are healthy and unlikely to benefit from them.

The most visible example of this is the U.S. cesarean section rate: about one in every three women gives birth by cesarean. Cesareans can be lifesaving and health-enhancing in emergency situations, but unnecessary cesareans expose more mothers and babies to risks, without any clear gains for maternal and infant health overall.

Too many women are subjected to these potentially harmful procedures without giving informed consent.

In Childbirth Connection’s national survey of women who gave birth in U.S. hospitals, Listening to Mothers II, participants overwhelmingly agreed that women should know the potential harmful effects of procedures. Yet far fewer than half of women were able to correctly answer basic questions about the risks of labor induction or cesarean surgery, even if they had experienced these interventions themselves. In addition, nearly three-quarters of women who had episiotomies (a surgical cut to make the vaginal opening bigger during birth—a painful procedure associated with known harms when used routinely) did not give consent.

Too few women have the benefit of low-tech supportive care practices that help them safely cope with the demands of pregnancy, labor, and birth.

In the Listening to Mothers II survey, most women said they were not allowed to drink or eat food, were confined to bed once admitted to the hospital and in “active” labor, and gave birth lying on their backs (a position that is more painful than upright positions and poses challenges for giving birth). Only two percent of women experienced a set of five supportive care practices that research shows benefit mothers and babies.  These practices are: labor begins on its own; the woman has the freedom to move and change positions; the woman has continuous labor support from a partner, family member, or doula; the woman does not give birth on her back; and the mother and baby are not separated after birth.

Too many women end up with physical and emotional health problems after giving birth.

In a follow-up survey of Listening to Mothers participants, many women experienced pain, physical exhaustion, and sexual problems lasting months after birth, as well as shorter-term problems such as infection and rehospitalization. Most had some symptoms of postpartum depression in the two weeks prior to the survey, and nine percent of mothers appeared to be suffering from childbirth-related post-traumatic stress disorder.

Roadblocks to Change

Why are some medical interventions still being overused in the United States today, despite the evidence against them? And why aren’t approaches that are known to be helpful offered to all women? Advocates for improving maternity care point to the following roadblocks to change.

Obstetrical training and the medical system

Obstetricians provide care for the vast majority of pregnant women in the United States. Obstetricians’ training emphasizes identifying and managing the complications of pregnancy and childbirth. They generally receive much less instruction in the natural progression of childbirth or in low-technology techniques that minimize problems. While doctors trained years ago learned to safely deliver breech and twin babies vaginally, newer doctors have not learned these skills, as the standard of care has shifted to require cesarean for such births.

Economic incentives

Surgical interventions can save doctors time and money. Many payment systems offer a single or fixed fee to doctors, regardless of whether a baby is born vaginally or by cesarean, and others offer a larger fee for a cesarean. Therefore, doctors who patiently support natural labor, which starts at unpredictable hours and generally requires more time, are penalized financially. Scheduled inductions and cesarean sections help hospitals make nursing staff schedules more predictable and shift more of health care providers’ work to convenient weekday hours. Nondrug methods of pain relief and the one-on-one nursing care that enables natural labor are not billable to insurance, while epidurals and other anesthesia services are major sources of revenue for hospitals.

Fear of lawsuits

If something goes wrong, doctors may be blamed for not doing something, but rarely are they blamed for doing something that is not necessary. For example, malpractice lawsuits for not performing a cesarean section are much more common than lawsuits for doing one when it wasn’t necessary. To avoid litigation, many doctors and some midwives report that they feel compelled to do “too much” rather than be accused of doing “too little.”

A rushed, risk-averse society

The desire to eliminate pain and control outcomes may cause both health care providers and expectant parents to embrace unneeded and potentially harmful procedures. Healthy women with low-risk pregnancies receive treatments that were designed for use by women with high-risk pregnancies. The widespread use of epidurals also has transformed childbirth in the United States. Though epidurals are in most cases a very effective form of pain relief during labor, they sometimes have adverse effects and require the proactive use of other interventions to keep mothers and babies safe and labor progressing.

The language of “choice”

Labor and birth approaches are sometimes presented as equivalent “choices” without full, accurate information about their potential consequences. Choices that are perceived as risky for the fetus are more likely to be restricted than choices that are clearly shown to be risky to women. For example, vaginal birth after cesarean (VBAC) and planned home birth, though both are supported by research, are seen as unreasonable and inaccessible to many women, while elective cesareans (cesarean sections done without a medical need) are increasingly presented by the media and some doctors in a misleading fashion as a reasonable option for healthy pregnant women.

Working Toward Change

Many people are working to challenge and change birth practices that aren’t in the best interests of women and babies. Such advocates are addressing a range of problems, from the overuse of unhelpful medical interventions, to the lack of continuous care available to laboring women, to rules that prevent pregnant women who have had previous cesarean sections from trying to give birth to subsequent children vaginally. Their efforts have helped alter some hospital rules and routines for the better, although such attempts to create change often meet with resistance.

Below are some organizations working to improve the care all women and babies receive: