by Alan Lindemann, M.D.
Few times in our lives do we encounter better outcomes than we anticipate. I have been very fortunate in that when I was called upon to teach, I found I liked it much more than I ever thought I could. I found my practice to be more than I had ever hoped, teaching medical students, nurses, nurse practitioners, physician assistants, medical students, and residents. I found dozens of patients asking me to maintain their pregnancies. These were patients who had had failed pregnancies already, with non-viable fetuses.
Many of these patients were 14, 15 weeks up to 24 or 25 weeks of gestation without a viable pregnancy delivered. Several doctors in my area kept doing laparotomies on patients who couldn’t conceive and remain pregnant long enough to deliver a healthy fetus.
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
— William Osler
I developed a protocol for these patients who had failed pregnancies. It included checking for Ureaplasma, Myplasma, Chlamydia, and Gonorrhea as well as group B strep and B.V. It seemed to me that operating on these patients time after time simply generated more adhesions. Such a protocol would require searching for a possible underlying agent, usually infectious. Time after time these patients presented with underlying Urealasma, Mycoplasma, or Group B.
One of my patients, along with her husband, were English language teachers in China. She had six weeks here before they returned to China. I cultured and found Ureaplasma and treated both she and her husband with doxycycline, the choice of treatment available to me at that time. About 6 weeks later I got a call from China indicating my patient was pregnant. She told me she had failed in vitro pregnancies on four continents.
A Possible Solution for Maintaining Pregnancy
First of all, make sure there are no simple and reversible causes for pregnancy loss or preterm delivery. But over the years I have studied this problem, I have come to the conclusion that there should be specialty hospitals for pregnant women. Specialty hospitals do not need to maintain an emergency room 24/7 and are required only to treat their target audience.
So this hospital would be dealing only with obstetrics. There would be at least three midwives who knew every patient. One of them would be available in the hospital all of the time. There would be at least one physician who would be there all the time and had an opportunity to know every patient. Some of the midwives could be doubly trained as anesthetists and available 100 percent of the time.
Presently there can be much animosity between midwives who do home deliveries and physicians who are asked to receive home-birth patients if trouble arises. Some deliveries, whether in a birthing center or at home, will culminate in an emergency cesarean section. In a specialty hospital, there would be no arguing about whose fault the emergency was, with the mother and baby in the middle, but just getting the job done in a friendly and effective environment.
I strongly suspect the only way to get rid of the animosity between obstetricians and midwives not on hospital staffs is to create specialty hospitals where midwives and physicians work together. The trip to the operating room would be rapid and without confusion or delay. Delay, according to the Center for Disease Control, is one of the primary factors in many maternal mortalities and morbidities.
I have had the opportunity to work with lay midwives licensed in the state of Minnesota as well as licensed midwives in North Dakota. For the most part, midwives in the state of Minnesota did a better job. There are lay midwives in North Dakota, but the state refuses to license them. Nonetheless, these lay midwives all did good work.
I know of a physician who got into a lot of trouble from the medical board for giving Methergine to a lay midwife. This is not the street we need to be going down. We need to be working together. Women’s lives depend upon us to work together.
In one hospital I delivered in, I was able to let my high risk patients stay in rooms on the floor below for $15 a day. North Dakota is a rural state and many patients have to travel many miles to a hospital. Today there would be all kinds of resistance to this. Hospital CEOs would complain they needed to make far more money than that for a room. Lawyers would complain because there was no nurse on the floor. Didn’t matter that the nurse was a flight of steps away. As soon as nurses are involved, the rooms are no longer $15 a day, but $1000 or more a day. If necessary, a CNA could be on the floor, but there was really no need for an RN under the circumstances. There was a time insurance companies might have been interested in the $15 a day instead of $1000 a day, but they might have to lower their premiums for the $15 a day accommodations.
The notion of the obstetric hotel idea is not new. The nuns have practiced the hotel model, but that ended 60 or 70 years ago. Only with a specialty hospital could we keep high risk patients close to careful observation and provide good outcomes without animosity.
Uterus the Best Incubator
Most of the time, the uterus is the best and most cost effective incubator. A birthing center hotel as part of a specialty hospital prevents unneeded cesareans just to get patients out of the hospital in the time allowed by insurances. I’ve been told that a nearby hospital now starts all inductions at five minutes past midnight to accommodate the insurance company demands for short stays.
The baby should be able to decide when to be born, as has been the case for centuries. Taking babies from women to meet a time table of an insurance company is not only inhumane, but also terribly expensive. Motels today would cost more than $15 today, but even at $50 a day, an obstetric motel saves money. The cost of a day in the NICU at $25,000 to $50,000 a day is far greater than the cost of a month or two in an obstetric motel which allows a high risk mother to deliver a healthy baby.
An obstetrical hotel is not a new idea. But it’s an idea which I believe would have a significant effect in reducing maternal mortality and morbidity, and hence, is an idea which deserves to be considered for revival. So as Zig Zigler said, “If we always do what we’ve always done we’ll get what we’ve always got.” It’s time for a big change, a change long overdue.
The cost for a vaginal delivery is approximately $11,000 a day. We really cannot go on with that. Insurance companies really have no vested interest in reducing costs because they can continue to increase their rates. On top of raising rates, insurance companies have been allowed to tell physicians what they can and can’t do, like keep a mother in the hospital for an additional day if needed. Premature discharge of babies prevents staff from watching to see if the parents know how to feed a baby and recognize if it’s hungry. When mothers could spend more time in the hospital, there was plenty of time to help them learn how to care for their infants. Years ago patients were sent home when they were ready to go. Physicians decided when they were ready. Every morning we made rounds the nurses would tell u s which patients were ready to go, whether there was enough milk, and whether it would take another day or two for all to adjust appropriately. Today patients are handed a bunch of videotapes and that counts for teaching. Nothing could be more ridiculous.
In summary, the insurance makes the rules and the physicians are forced to follow them, causing a great deal of harm to many people, both mothers and babies. Doctors need to take back control of medicine. The physicians and patients should be in charge of determining what care is needed. The lives and well-being of pregnant women will depend upon it.
Listen to your patient, he is telling you the diagnosis.
— William Osler