Thursday, March 7, 2013

Quick Hit: #IOMbirth

I've been watching and livetweeting the IOM Workshop on Research Issues in the Assessment of Birth Settings. I have a too-long-to-tweet thought and so am breaking my nearly-year-long blog silence to get it out (Woops! Hi! I did my practicum, got pregnant, graduated, and moved to Germany, so things are a little out of date around here! More later!).

My thought is about the one-way traffic that characterizes birth settings in the US. As you can see in the infographic IOM made for the occasion, a scant 1.2% of US births happen in out-of-hospital (OOH) settings. I don't know that there's good data on how many more people start out their pregnancies planning on OOH settings - let's be generous and say 5%? It can't possibly be more than 10%, right? Giving us 90% starting out in-hospital?

But the moves that happen during prenatal care (I'm not talking about tranfers/transports here) are almost entirely going to be from that already-small OOH group to hospital settings. People "risk out" and get moved (appropriately, in many cases) to settings designed to deal with higher-risk situations.

What doesn't happen: people attending prenatal care in a hospital being told, "You know what? Your pregnancy is totally normal. This is overkill. You should be at a birth center (or at home) instead." This despite that the numbers are totally disproportionate in the opposite direction (e.g. those who start in OOH settings and should move to hospitals are a tiny fraction of those who start out in-hospital and could (should?) move to OOH settings.)

Of course, what I'm leaving out here is the same thing that the IOM has totally left out of the Workshop (as Jill pointed out weeks ago) - patient voices, preferences, and rights. Think about this issue (the fact that the status quo has a huge percent of childbearing persons starting out and remaining in-hospital to give birth) from a patient-consumer perspective. Unless you're part of the 1.2% (or 5%, or whatever) fringe that happens to a) know about OOH options and b) be realistically able to access them, you'll give birth in the hospital. There's no system in place to get you to the most appropriate care, unless you're in the bitty percentage of folk who start OOH and get risked out.

That's not fair to anyone - not to hospital providers who treat a population that is overall vastly too healthy to take proper advantage of their medical expertise, not to OOH providers who end up working in an antagonistic system with an artificially limited patient population, and certainly not to patient-consumers who too often end up overtreated and iatrogenically harmed.

(All this having been said, I do want to affirm that choice in place of birth is an important right. While at a system level, referrals should happen in both directions (OOH->hospital and hospital->OOH), individuals should retain the right to opt for one or the other. The two possible mismatches here have different characters: people with uncomplicated pregnancies who want to give birth in hospital (sure! go for it!), and people with complicated pregnancies who want to give birth OOH. Finding the right solution for the latter group is HARD, mostly because of effects on providers (I believe the patient's right to choose is absolute in theory but at some point the state has a role in restricting risky practice on the part of providers). Too big and messy of a topic to get into here, but note that this group has been getting a disproportionate share of the IOM conference attention compared to the superset of all people giving birth or suited to give birth OOH.)

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