A Tale of Two Hospitals - part 2 - By Rachel Frier Carbonneau

Comparing two examples of hospital birth scenarios part 2 of 2 (read part 1 here

By Rachel Frier Carbonneau
Doula, Childbirth Educator, Wellness Coach


So, then, what difference does it make where you birth? What impact will it really have on your overall labor and birth experience?

By the Numbers

Where you birth can have a tremendous impact on your birth outcomes. Having looked at two different hospital models, let’s look at the statistics on birth outcomes at each.

Hospital A overall boasts some pretty good birth stats, which means they must be doing something right. The hospital has an overall relatively low self-reported 62% medical intervention rate, and a documented 35.4% C-section rate, only slightly above the U.S. national average of 32.7% (and the World Health Organization (WHO)’s recommended rate between 10-15%). However, the hospital does have a Level IIIB Neonatal Intensive Care Unit (NICU), the use of which indicates that the hospital handles some very delicate pregnancies.

Hospital B has a self-reported 97% medical intervention rate, and a self-reported 44% C-section rate, well above the U.S. national average of 32.7% (and the WHO’s recommended rate between 10-15%). But this hospital has only a Level II NICU, meaning they don’t attend to the tiniest preemies or the sickest newborns, who would have to be transferred elsewhere for care.

The overall numbers seem in stark contrast—and it is worth noting that the birth outcomes for mother and baby seem to be largely different. In Hospital A, mothers have fewer interventions and fewer C-sections, but the hospital attends to more fragile babies. In Hospital B, the mothers have more interventions overall, and doesn’t have facilities for treating the most delicate babies. But numbers don’t tell the whole story….

Why the disparity in birth outcomes between Hospital A and Hospital B? It’s certainly very tempting to point fingers and say “aha! I knew the natural approach was better! Just look at the numbers!” or even to say “well, the reason Hospital Two has a higher C-section rate is that they take all the transfers of homebirths gone horribly wrong, and save these poor women and babies from the brink of death.” But neither statement would be accurate, and neither set of numbers really tells the whole story.

For one thing, there is nothing inherently wrong with a C-section, and to point at a high C-section rate as an indication that a hospital is doing a poor job of serving its clientele is to miss the entire point. A hospital with a high C-section rate serves clients who, for one reason or another, opt to go to that hospital. If you are dead-set against a C-section, this is probably not the hospital for you. But if you are a high-risk family that needs close monitoring by an obstetrician specializing in high-risk pregnancies, or if you are unable to access the services of a midwife or appropriate classes/resources to prepare for a natural birth, or heck, if you even just want a C-section… wouldn’t it make more sense to go to the hospital where this is a common procedure, and where they are likely to have more surgeons and anesthesiologists on staff?

For some, surgery truly is their only birth option. Midwives and some natural-childbirth obstetricians boast a high success rate in part because they handpick their clients, often turning away those who “risk out” or come with complications requiring direct medical oversight. This leaves obstetricians to manage these pregnancies and births, and they tend to do so with all the medical tools available to them. This is their training. This is what they know.

In a hospital accustomed to serving clients seeking pain-managed births, for a woman to request otherwise instantly pulls the hospital staff, nurses and otherwise, out of their established routine. If you go into a medication-friendly hospital telling them you don’t want to use their tried and true approach, no matter how willing the staff may be to oblige, you have already stacked the deck against yourself by denying them the comfort of routine. If you are planning a natural birth, find a hospital and a care 

provider who openly support that model. Just as you wouldn’t go to a mechanic and ask them not to work on your car, you shouldn’t go to a doctor/surgeon and tell them you don’t want medication/surgery.

Perhaps it is partly because of such crossed wires that so many births in Hospital B end up in C-section, even among mothers planning medication-free vaginal births. When a family shows up without a doula or other labor support, because the hospital cannot dedicate staff to that family alone such families are often left to labor on their own for what may seem like an eternity. The hospital is simply not equipped to provide adequate support in the case of a long labor that cannot be managed with Pitocin. Many families have no back-up plan when medical interventions do become indicated (for one reason or another), and one or two seemingly innocuous interventions quickly turn into a cascade.

Unfortunately, it’s the mamas in the middle of the spectrum—the high-risk mamas who want a natural birth, or the low-risk mamas who (for whatever reason) lack access to insurance coverage, information, or resources—who miss out the most. It’s these mamas who find themselves thrown over the barrel during labor, swept off their feet by a system purporting to support them through labor but unfortunately ill-equipped to do so. Because a hospital staffed by highly-skilled surgeons tends to serve a higher-risk population in general—mothers over 40, families with a history of illness, births of multiples, etc.—they are accustomed to working to mitigate those risks, typically by using whatever medical tools and implements are available to them. But sometimes, a mama who “risks out” of a midwifery practice’s care or does not have access to a natural-friendly hospital setting finds herself signed up for a long list of interventions she may not want.

The Bottom Line

“It doesn’t make any sense,” you’re saying. “The numbers don’t lie! Why would a hospital openly promote interventions and medication in birth, when the outcomes for natural birth seem so much better?”

There are a variety of reasons, I’m sure, on which I cannot even begin to speculate. I can say that many hospitals openly favor the epidural because it means you will require less personal attention—you can sleep or watch TV through your labor, and won’t need someone by your side to coach you through frequent and intense contractions. Doctors can check in on you according to their availability, and can speed up your labor with Pitocin without concern of added discomfort.

See, a hospital is a business like any other, and each bed represents a certain dollar value in revenue. The longer you are in a bed, the more space you may be taking from another potential birther. Doctors expect you to come in during active labor, and they expect that labor to progress to near completion within 12 hours—otherwise, you are “hogging” space that might go to another of their patients. The ever-rising costs of medical liability and malpractice insurance necessitate that doctors maintain a very high caseload, but that means less personal attention for you, and less time to “rent” your space in a hospital bed. (Unrelated to birth, another specialist told me that insurance companies recommend he spend no more than 15 minutes with each patient—15 minutes!!)

And that is the standard among doctors who truly wish to help you have a vaginal birth. There are other doctors who, anecdotally, rely on the revenue generated from C-sections, which often cost at least twice as much as a vaginal birth. This is one concern many have with allowing surgeons to attend births. There is also a method called “Pit[ocin] to distress,” which is not condoned by anyone in the birth 

community and is rarely spoken of, as it falls into a category of medical abuse of power. Fortunately, in my work in my local area, I have yet to witness this. But I hear stories from colleagues around the country, and it is worth being mindful if you are with a provider with an unusually high C-section rate. As a matter of fact, it’s worth being mindful of the “C-section epidemic” in general (and the American College of Obstetrics and Gynecology (ACOG)’s stance on prevention of primary C-sections), especially if a C-section is not part of your birth plan.  

But remember that you have rights and options no matter where and with whom you choose to birth. Though your options may be limited by insurance coverage, risk factors, or your family’s particular needs, in all circumstances you have the right to make the choice that is best for you. By being an informed consumer and learning about your options, you can speak openly with your care provider and gather vital information that will help you navigate your birth experience.

The bottom line is that there is no right or wrong way to birth—the choice of birth place and birth team is yours alone. But the responsibility to prepare appropriately is also yours. Regardless of which type of birth you are choosing, there are a number of steps you can take to prepare yourself for the big day, and for the experience you are expecting and hoping for.

  • Take a childbirth class. You don’t know what you don’t know, and a childbirth class—especially a class series of several weeks or more—can help fill in information gaps and prepare you for the big day. (There are several major “schools” of childbirth education, the Big Three being Bradley, Hypnobirthing, and Lamaze. But plenty of other styles and types are available as well.)
  • Hire a doula. A trained and experienced labor companion can offer invaluable guidance and advice, and can coach you on the right questions to ask to get the information you need for truly informed decision-making, through your pregnancy and labor. Think of your doula as a birth tour guide, helping you experience all the highlights of birth while avoiding the sketchy neighborhoods.
  • Spend as much time (or more!) preparing for your birth as you did for your wedding. You can only have the birth you have prepared for, and it is not up to your doctor, nurses, or doula to drag you through if you come in unprepared and things start to go off course. Your medical staff will keep you healthy, and your doula will offer physical and emotional support, but creation of the birth experience is up to you.  
    • If you want a natural birth, find a midwife or obstetrician who specializes in this approach. It’s not enough to simply ask if a doctor supports natural birth. (Would any doctor really say “no”?) Do your research. Sites like Yelp and MedAdvice are a great way to get feedback about potential care providers. Polling your friends is a great way, too, since you likely trust their advice (or at least know something about the source).
    • Understand the risks associated with the use of pain medications. Though it is often touted as a wonder drug or the only way to get through labor, it’s important to remember that is not like Advil or Tylenol: it doesn’t work the way you think it will, and it doesn’t work the same way for everyone. And there may be lasting complications, not least of which are a slowed labor and prolonged recovery time. Be sure you take the time to read and prepare.
    • Be an informed consumer and learn about the risks and benefits of different interventions. It is very rare that I see a doctor actually sit with a family and explain the pros and cons of different interventions. Sometimes, there simply isn’t time. Sometimes, additional interventions have to be introduced to counteract earlier interventions (this is known as the “cascade of interventions”). A healthy dose of information in advance can save you from a lot of confusion—and possibly unnecessary interventions—once in labor. (See notes on childbirth education above.)
    • Speak directly with your care provider about your role in preparing for your birth. Your care provider will likely be thrilled to see you taking an active role in preparing for your birth and working as part of the team. Ask your doctor how you can prepare, and you may be surprised at the amount of advice you get!
    • Take nothing for granted. Your parenthood journey starts now.

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