Troubled Labour

Both the US and India fall short on care of women during childbirth

Providing too little care too late or too much care too soon are challenges that both maternal health systems face.

After eight years of practicing obstetrics and researching childbirth in the United States, I know as well as anyone that the American maternal health system could be better. Our way of childbirth is the costliest in the world. Our health outcomes, from mortality rates to birth weights, are far, far from the best.

The reasons we fall short are not obvious. In medicine, providing more care is often mistaken for providing better care. In childbirth the relationship between more and better is complicated. Texan obstetricians, when compared to their counterparts in neighboring New Mexico, are 50% more likely to intervene on the baby’s behalf by performing a cesarean section. Nonetheless, Texas babies still have a lower survival rate than New Mexican babies.

I long assumed that our most puzzling American health care failures were idiosyncrasies–unique consequences of American culture, geography, and politics. But a trip to India for the 2017 Human Rights in Childbirth meeting led me to a humbling realization: when it comes to childbirth, both countries fall short in surprisingly similar ways.

Human rights in childbirth

I take care of patients in at a well-funded teaching hospital in Boston, where pregnant women seem well-respected and have clear, inviolable rights.

I’ve read about the gender-based violence, the profoundly disturbing cases of disrespect and abuse that too many women in India and around the world experience. But these are not things I have deep experience with.

I initially hesitated when I received an invitation to speak at a human rights meeting. Still, the opportunity to scrutinize my profession alongside international experts from a broad range of disciplines was compelling. Over 200 activists and scientists, midwives and physicians, journalists and attorneys planned to discuss strategies to advance justice, dignity, and respect for pregnant women. So I got on the long flight from Boston to Mumbai.

The meeting began with Indian women describing their experiences of care gone wrong. Many were heartbreaking stories of women receiving too little care too late – failures to provide antibiotics, blood and other forms of resuscitation in a timely way. Others were equally heartbreaking examples of women receiving too much care too soon – unnecessary inductions of labor, episiotomies and C-sections. Beyond instances of clinically measurable harm, the stories illustrated routine misappropriations of care that these women felt deprived them of basic dignity.

Throughout, I was conscious of the fact that Indian clinicians have different training and face different constraints than I do. Indian women often have less agency to advocate for themselves compared to American women. Nearly half of Indian women are married before the age of 18 and have limited capacity to make independent decisions regarding reproduction. Indian women also have less access to basic social services than American women, though they are far more likely to require them. Higher rates of chronic and infectious diseases, higher rates of illiteracy, higher rates of abject poverty are all factors contributing to avoidable suffering in childbirth.

But as I sat there, listening to case after case, aware of the differences between the American and Indian context, much of what I was hearing also sounded uncomfortably familiar. Fundamentally, providing too little care too late or too much care too soon are challenges that all maternal health systems are confronting, including the American system. And in America, India, and many other countries, the standard approach to address these challenges is similarly limited.

The principal way my profession aims to improve care is by issuing guidelines that spell out the things we should be doing more of. But simply advocating that we start to do more things may be inadequate. In many cases doing more can actually be harmful.

Too much care or too little?

In a recent Lancet commission on maternal health, 77 researchers from around the world, including me, concluded that our primary struggle in maternal health care is to find the appropriate balance – to provide the right patient with the right care at the right time.

The testimonies during the conference revealed a startling set of facts. In India, as in the United States, the biggest risk factor for getting an avoidable and potentially harmful c-section appears to be which facility a woman goes to for care, not her personal preferences or medical risks.

In India, as in the United States, those facilities that are better at achieving the right balance of interventions rarely share best practices with others. And in India, as in the United States, efforts to elicit and attend to the legitimate preferences women may have during childbirth are the exception rather than the rule.

These parallels have their limits. On average, health outcomes in the United States are significantly better than those in India. But this mode of comparison misses a critical point. Dignity is a consequence of appropriate care, and appropriateness cannot be easily determined by population statistics. In our intense focus on mortality rates, we often overlook the obvious fact that childbearing women have goals other than emerging from birth alive and unscathed.

Childbirth is a moment of identify formation as a mother. It is a moment of profound self-agency (or lack thereof). It is a moment that nearly all my patients tell me has long-lasting and nuanced effects on their lives, though we do not have good ways of measuring such things.

More than safety

The stories of care gone wrong in India gave me an uncomfortable feeling that even the routine, seemingly respectful and safe care I provide in Boston may occur in a system that may not be designed to prioritize the dignity of my patients.

A large part of the challenge is that many women may not know what they deserve when it comes to the experience of having a baby.

An impoverished Indian woman who treks to civil hospital, only to give birth through an avoidable episiotomy, with minimal labor support, on a dirty metal cot, in a room crowded with other patients, may see that as normal. She may even expect it.

Of course, an American woman who labors in a clean, private room, within a state of the art hospital, only to receive an avoidable c-section will often see that as normal as well. In both cases, as long as the baby is healthy, women are almost always grateful.

Photo: George Ruiz/Flickr
Photo: George Ruiz/Flickr

Those of us in the birth community could do better in helping women understand what they deserve, and in developing systems of care that deliver on this promise. But first we have to be willing to link the ideas of appropriateness and justice, of patient experience and dignity. In other words we have to be willing to see childbirth through the lens of human rights.

As an obstetrician, I understand the hesitation. There’s a part of me that still bristles at this framing. In practice, knowing when to intervene in the course of an otherwise healthy woman’s labor can be incredibly difficult. Perfect accuracy may actually be impossible.

Yet there are certainly broad ways that the American maternal health system can do better. About 50 percent of U.S. counties lack any qualified childbirth provider, limiting access to necessary care. Paradoxically, when we do provide access to care, we tend to provide too much. In the case of unnecessary c-sections, the error margin is again about 50 percent.

While perfection may not be a reasonable goal, delivering appropriate care with the same success rate as a coin flip is not reasonable either. In fact, it is unjust.

The writer is an assistant professor of obstetrics, gynecology and reproductive biology, at Harvard Medical School.

This article was first published on The Conversation.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.