If you've been paying any attention to the health care reform conversation in this country, you've probably heard of a certain New Yorker article, in which physician Atul Gawande pays a visit to McAllen, TX, the town now infamous for having the most expensive health care in America. With truly exemplary investigative reporting, Gawande explores the factors that have driven the soaring health care costs in McAllen and presents a strong case that this increased spending has not improved the health of the people living there. In fact, he argues, it may be making them sicker. If you haven't already read the article, please do.

Atul Gawande is not only a world-renowned surgeon and best-selling author, he's also a MacArthur 'Genius Grant' recipient. And rightly so. Among his many other achievements, his analysis of the health care 'cost conundrum' is brilliant. So brilliant that President Obama has reportedly made it required reading among his staffers and advisers. I knew the article was something serious when prominent medical blogger Kevin Pho professed on his Twitter feed, 'If you only read one health policy article in your lifetime, this one is it.'

I devoured all 8,000 words of it. But, to my astonishment, I found not a single mention of maternity care, despite the fact that hospital charges for maternal and newborn care far exceed those for any other condition, and the clear evidence that there is ample room for cost containment and quality improvement. I wondered how this article got researched, written, and published with such a glaring omission.

Then I remembered something. There's another article Atul Gawande wrote, this one devoted to maternity care.

In his 2006 article, How Childbirth Went Industrial, Gawande follows a woman - a doctor herself - in labor with her first child. She begins the process hoping for a healthy birth with the least intervention possible. She ends with an epidural, pitocin augmentation, and eventually a cesarean section of her healthy baby after labor fails to progress. Gawande uses this all-too-common story as a backdrop to follow the history of modern obstetrics and to illustrate that, while evidence documents the harms of the routine or liberal use of many obstetric interventions, the 'package' of high-tech maternity care nonetheless is responsible for the steep declines in maternal and neonatal deaths we've seen since the dawn of obstetrics. Along the way, he argues that broad improvements in maternity care were only possible by reining in the wide variations in obstetric practice that were once commonplace, such as the differences across doctors in the skill and safety with which they performed forceps-assisted deliveries or managed difficult vaginal breech births. Reducing this variation, he contends, required a shift from the 'obstetric arts' that were difficult to teach and master consistently to a more measurable, standardized brand of obstetrics. The lamentable but worthwhile result was a rise in the use of cesarean surgery which, according to Gawande and those he interviewed, is 'easy to teach,' 'comfortable' for obstetricians, can be performed 'consistently,' and is a 'simpler, more predictable way to intervene.' Today, cesarean surgery is used to accomplish one out of every three births in the United States. (For those interested, Henci has done a more detailed critique of this article.)

Gawande acknowledges cesarean's risks:

Straightforward as these operations are, they can go wrong. The child can be lacerated. If the placenta separates and the head doesn't come free quickly, the baby can asphyxiate. The mother faces significant risks, too. As a surgeon, I have been called in to help repair bowels that were torn and wounds that split open. Bleeding can be severe. Wound infections are common. There are increased risks of blood clots and pneumonia. Even without any complication, the recovery is weeks longer and more painful than with vaginal delivery. And, in future pregnancies, mothers can face serious difficulties. The uterine scar has a one-in-two-hundred chance of rupturing in an attempted vaginal delivery. There's a similar risk that a new baby's placenta could attach itself to the scar and cause serious bleeding problems. C-sections are surgery. There is no getting around it.

And yet, he concludes, 'In the next decade or so the industrial revolution in obstetrics could make cesarean delivery consistently safer than the birth process that evolution gave us.' How do we reconcile Gawande's cogent plea to curb our over-dependence on medical technology with such a claim?

Granted, one article looks historically while the other comparatively. In How Childbirth Went Industrial, Gawande asks how we wound up with this current style of maternity care. In The Cost Conundrum, he compares McAllen to El Paso, where the population is similar, the costs are lower, and the outcomes are superior. But How Childbirth Went Industrial completely misses the same issues so ably analyzed in The Cost Conundrum even though they were staring Gawande in the face. He gets what is going on in McAllen but not what is going on with U.S. obstetric management, namely that other care models result in better outcomes and that obstetric management is driven by economic self-interest.

If Gawande wanted to do some McAllen-style journalism on maternity care, he could have visited Miami-Dade County, Florida, where more babies are born by cesarean than vaginally and one hospital has a 70% cesarean rate. He could have compared costs and outcomes in Dade County with those in, say, one Indian Health Service hospital in New Mexico, where the c-section rate in births at or beyond 35 weeks is below 10%, despite much higher rates of diabetes, pregnancy-induced hypertension, and medically-indicated induction of labor compared with national statistics. (While he was in the neighborhood, he could have checked out excellent outcomes in the rural area nearby where two-thirds of women give birth in a maternity hospital without any surgical or anesthesia facilities at all.) If he was feeling adventurous, he could have crossed the pond to virtually any European country and found lower per-capita costs, far better outcomes, and much less reliance on surgical obstetrics. Not coincidentally, he might also have noticed that had he sat down for dinner with the system's gate-keepers abroad, as he did with six doctors in McAllen, this time he would have dined mostly with midwives. That's because in countries with the best outcomes, midwives far outnumber obstetricians, whose specialist expertise and surgical skills are reserved for complicated and high-risk cases.

Gawande saw a fall over time in perinatal and maternal mortality and attributed it to advances in hospital-based obstetrics. But he knows as well as anyone that correlation is not the same as causation. While a few medical advances - oxytocics and ergot derivatives to control hemorrhages, antibiotics to treat infection, and surfactant to treat respiratory distress in premature infants - have certainly prevented deaths, much of the fall in mortality likely comes from basic improvements in public health and hygiene. By looking through the bifocal lenses of medicine and history, Gawande makes an erroneous assumption that, when it comes to giving birth, more technology is inherently better. What he fails to ask is the very question at the heart of The Cost Conundrum: could we get the same or even better outcomes with fewer risky and costly procedures?

So, to all you White House staffers, policymakers, and reform advocates out there, allow me to help answer this question. If you only read two health policy articles in your lifetime, make the second one this.

Read this!

Published: June 27, 2009

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