00:07 Trevor Burrus: Welcome to Free Thoughts, I’m Trevor Burrus.

00:09 Aaron Ross Powell: And I’m Aaron Powell.

00:10 Trevor Burrus: Birth and death are profoundly personal experiences, bound up in our beliefs, religious faith and cultural values. And in the last century, various forces have medicalized birth and death, pushing us into hospitals and promoting a one‐​size‐​fits‐​all approach.

00:23 Aaron Ross Powell: The government has been one of the central forces in this transition. By designing hospitals, licensing midwives, eliminating birthing centers and hospices, and controlling the money that flows through our healthcare system, the government has pushed us into hospitals and eliminated other options.

00:38 Trevor Burrus: On today’s episode, we discuss how this happened and what we can do about it. Joining us today is Lauren K. Hall, an associate Professor of Political Science at the Rochester Institute of Technology. Her new book is The Medicalization of Birth and Death. Welcome to Free Thoughts, Lauren.

00:53 Lauren Hall: Thanks so much for having me.

00:55 Trevor Burrus: It’s an interesting title, Medicalization of Birth and Death. It seems like they are inherently medical things, so how have they become medicalized?

01:06 Lauren Hall: Yeah, I would actually push back on the idea that they’re inherently medical. Birth in particular I think is not, in fact, a medical problem at all. It’s not an illness, it’s not a disease. Many births have medical components, but that’s quite different from the contention that I think we see now, which is that birth is inherently a medical phenomenon. And the same thing is sort of true of death, although it’s a little bit more complicated because of course usually people die of specific diseases or illnesses. And so what I’m looking at in the book is the shift that happens over the last really 100–150 years, from birth and death primarily happening at home with informal caretakers to largely taking place in centralized hospitals. And so my argument is not to throw things back to the home and unpaid labor and things like that, but instead to try to find some middle ground where we recognize when medical attention is needed and when medical intervention is called for, and when we’re actually harming people by using medical tools on them during these really vulnerable times.

02:23 Aaron Ross Powell: So, a lot of people listening to that they may say, “Okay. Yes, birth in particular is not a medical thing in the way that cancer is, or it’s not a problem to be “solved”, but at the same time, over this 150‐​year period that you mentioned, things both birth‐​wise and death‐​wise seem to have gotten better, like our life expectancy has gone up, so we’re dying at later times too. And birth is far less dangerous than it used to be, and it would seem that a lot of that is because we’re doing it in places like hospitals. So even if we go in and aren’t treating it like a medical condition that has to be solved, isn’t the fact that we’re doing these things in hospitals where we’re surrounded by high quality equipment, high‐​quality care, people who can jump in if something goes wrong, isn’t that making these things necessarily better?

03:16 Lauren Hall: The medical research suggests not. So if you look at the actual medical research on both birth and death, we seem to have reached a tipping point where we provide far too much care. It’s absolutely true that in the course of the 20th century, we developed medical innovations that allowed for women to survive hemorrhages, for example, that would have killed them even 10 years earlier. We managed to make C‐​sections much safer, much more effective, much easier on both mothers and infants. And as a result of C‐​sections, of course, we’ve saved countless lives of both mothers and babies. So all of those things are good. Similarly, on the death side, chemotherapy is a fantastic innovation that saves thousands and thousands of people. But all of the available medical evidence that we have is that we use tools like chemotherapy and like C‐​sections far, far too often. So, in the US the C‐​section rate is about 32–33%. Most neutral observers would say that the ideal rate would be somewhere around 20%. Some people, the World Health Organization, gets it as low as 15%. That number is a little bit controversial. So we’re giving maybe a third of the women who are getting C‐​sections right now don’t need them.

04:38 Lauren Hall: And C‐​sections are an incredibly invasive. I mean, they’re major abdominal surgery. And then you send women home and expect them to take care of newborns after having major surgery. And then there’s compounding risks in later pregnancies, so the risk of various kinds of placental problems increases if you have an earlier C‐​section. So there’s all these problems that sort of compound that people don’t often take into account. And the same thing is true of chemotherapy. So, if you look at chemotherapy rates, chemotherapy is very commonly used in patients for whom there is no hope. And a lot of the research and palliative care, for example, suggests that if we send people home into palliative care, hospice care, people can actually live longer without chemotherapy than they do with chemotherapy. Because chemotherapy is actually a poison, and so if it’s not killing the cancer then it’s actually killing you. And Chemotherapy and C‐​sections are just one example of this phenomenon where it’s not that the medical tools themselves are inherently bad, by any stretch of the imagination. If I get diagnosed with cancer I absolutely want chemo to be available to me. But what we’ve done is we’ve medicalized these conditions to the point that we now provide too much medical care that actually is harmful.

05:56 Aaron Ross Powell: How much of this is about the difference between generalized statistics and, I guess, individualized risk, in the sense that we can say, like C‐​sections, that broadly speaking we’re doing too many C‐​sections but for any individual mother who goes into the hospital it seems perfectly rational for her to say like, “If there’s any risk that the birth would go wrong without the C‐​section, we might just wanna just take the C‐​section”. Or with the chemotherapy, as you said, there’s evidence that some people will live longer without the chemotherapy, but we don’t necessarily know who those people are at an individual level. And so is it people kind of choosing rationally for themselves or doctors choosing risk‐​averse strategies on the individual level, but then the result is, at the aggregate, we end up with far too much use of these things?

06:48 Lauren Hall: I think there are some of those cases on the margins. So, there are absolutely people who you just don’t know whether the C‐​section is the right move, but it’s the risk‐​averse move and so you’re gonna make that move. And same thing is absolutely true for chemotherapy. If you’re a young person with stage 4 cancer, you are going to be risk‐​averse, you’re gonna take the gamble against death. And so you’re going to take that chemo. But the research suggests that that’s actually not what’s going on. It’s going on in marginal cases, but that’s not what’s going on in the majority of the medicalization. What actually seems to be happening, and birth is a really good example of this, is that physicians are actually confusing, or at least choosing, their risk factors over the actual risk factors of the patient in front of them. So to take, for example, vaginal birth after Cesarean, the actual risk to any individual woman who wants a vaginal birth after Cesarean, which is a totally medically… I mean, all of the research supports that in the majority of cases VBAC is a safer option than a repeat Cesarean, but there’s one person for whom that is maybe not true, and that’s for the physician.

08:02 Lauren Hall: So the liability risk of VBAC is worse for the physician than the liability risk of a repeat Cesarean. And so when you look at VBAC rates across the United States, what you find is that women are themselves low‐​risk VBAC candidates, but because doctors are assessing their liability risk of something going wrong in the case of a VBAC, they are encouraging, or in some cases, honestly, pushing, sometimes even bullying, coercing women into repeat c‐​sections because it lowers their liability risk, not because it lowers the woman’s medical risk.

08:43 Aaron Ross Powell: How does the disconnect there though work? So insurance and liability, they’ve put a lot of effort into trying to figure out what the actual risks are, ’cause that’s how insurance companies make their money, is to be as accurate as possible there. And so how does that disconnect work in that you have a woman who the risk is low, but the insurance, the doctors caring is saying that the risk is high?

09:08 Lauren Hall: Yeah, there’s two things at work. One is a series of poor research that… Or a cluster of poor research that came out in the 1990s, that looked at uterine rupture rates in VBAC. And when those came out they… I mean, what it looked like was that you have these catastrophic uterine rupture rates. And so, “VBAC is dangerous, you don’t want the uterus contracting after it’s been cut open and so we should just totally cut VBAC out”. Up until that point, we had actually had relatively high rates of vaginal birth after Cesarean in this country. So, after that came out doctors and insurance companies dramatically cut back on their VBAC, or their willingness to attend VBACs. It became really clear later that that research was actually flawed in a variety of ways. One of the reasons that, and this goes to the medicalization piece, one of the contributors to uterine rupture was actually because we were inducing contractions with Cytotec, which is a very strong medication that causes extremely strong contractions that can in fact rupture a uterus. So it wasn’t the actual sort of natural contractions that a body goes through when it releases oxytocin, it was the fact that we were adding a medication to an already somewhat fragile environment that was then causing the ruptures. So, once people took Cytotec out of the protocol, uterine rupture rates went down dramatically.

10:37 Lauren Hall: The other thing that comes out of that is that people were misinterpreting what the data actually said about uterine rupture. So, “uterine rupture” sounds horrific and catastrophic, I certainly would never like to have a uterine rupture, but the reality is that the vast majority of uterine ruptures that occur during VBACs are minor tears that are actually very easy to… You can even repair them laparoscopically. So they’re not the kind… When we think “uterine rupture” we think catastrophic, life‐​threatening hemorrhage. That’s not actually what’s happening in the vast majority of these cases. So if you look at even the cases that have uterine rupture, the vast majority of them are minor. And the really serious uterine ruptures are a very, very tiny percentage of the total. So we’re sort of… It’s like we’re misinterpreting the risk that exists and then amplifying that risk into something that is actually not the case. And then what happened was a series of professional organization recommendations by the American College of Obstetricians and Gynecologists, ACOG, that came out and said, “Well if you’re gonna look at a VBAC, if you’re gonna attend a VBAC birth, you have to sit there the entire time”.

11:46 Lauren Hall: The doctor has to be in attendance the whole time. You can’t leave the room or you can’t leave the hospital, you have to have all of these other things in place, you have to do continuous fetal monitoring. And once you put those into place, I mean, the average C‐​section takes less than half an hour. A vaginal birth can take 8, 9, 10 hours. So, it just became completely economically irrational for doctors to support VBAC. There’s just no reason to do it if it takes you eight hours to do what you could be paid for 30 minutes of labor to do. So that’s sort of part of the the story there.

12:22 Trevor Burrus: And that gets to the question here, of how we got to this, with both the case of birth and death, And there’s multiple factors that we’ve already kinda touched on. Some of them liability, some of them funding. I mean, you’re not a huge fan of hospitals. You think they should exist, but it seems like you think that they had a interesting effect on American medicine.

12:43 Lauren Hall: Absolutely. And I’ll just preface this by saying, before the sort of the… [chuckle]

12:49 Trevor Burrus: Criticisms comes in? [chuckle]

12:51 Lauren Hall: Criticisms start coming in. I gave birth to all three of my kids in a hospital, I got pretty good care. We were happy to do it. Part of the reason that I gave birth in a hospital was that there were no available birth centers in my state, which we can talk about later.

13:06 Trevor Burrus: We can talk about why that is.

13:07 Lauren Hall: Yeah. But, yeah, I have nothing… I like hospitals a lot, for the purposes for which they’re designed. Which I think, hospitals are best reserved for treating acute or serious illnesses that require intensive medical care. The vast majority of births I do not think do that. And what ends up happening in hospitals, which indeed happened with all three of my labors, was that hospitals have to standardize care, just by the nature of the beast, right? This is true of any large bureaucratic organism, it’s true of any kind of institution that deals with lots of different people with lots of different modes of action and jobs that they have to get done. And so by having to standardize care it means that individuals who have unique needs are simply, by definition, going to be sort of “problem patients”. And this is certainly true of women who are trying to give birth vaginally. And it’s also true of many, many people who are dying. So, people who are dying are on very unique kinds of tracks.

14:19 Lauren Hall: And that’s partly because dying itself, if you are a terminal patient, there’s no curing death itself, you can hold it off with various kinds of ways but the process of dying, especially in the elderly and in the terminally ill, is an incredibly unique process. People have all sorts of preferences about how they die, about where they die, about the kinds of positions that they wanna die in, in terms of connection to social groups and family and things like that, that just cannot be managed in a hospital environment. And so that’s probably my biggest critique of hospitals, is not that they’re unnecessary or that they provide crappy care, although I think a lot of our incentives do point toward crappy care, but instead that they simply cannot individualize, care in the way that birthing and dying people require.

15:09 Trevor Burrus: And of course, since this is Free Thoughts, we have to blame the government at some point. I like the… One of the… This fact which I learned when I… Well, I helped review the manuscript, of this a couple years ago, this fact has stuck with me, that the Hill‐​Burton Act of 1946 gave us “the baby room”. That classic image of, in a movie, where you go in and look through the glass and all the babies who are lined up, is a product of government intervention, for these reasons about a factory‐​based model of a hospital.

15:49 Lauren Hall: Yeah, there’s this wonderful architect named Roselyn Lindheim, she’s unfortunately passed away now, and she didn’t leave a ton of research behind her, but she actually was one of the crucial architects in developing the concept of children’s hospitals. Because she looked at how we treat sick children in hospitals and she was horrified. This is like a situation where their childhoods are being taken away. So anyway, the the children’s hospital idea came from this idea of trying to de‐​standardize care for certain kinds of patients, so allowing children to have play rooms and allowing them to have sort of more open concept, allowing family more access and beds in‐​room so that parents could sleep with their children.

16:35 Lauren Hall: But she makes a similar comment about the Hill‐​Burton Act and its role in maternity care. So, as a hospital architect, she looks at this and she says, “This is insane”. Essentially the Hill‐​Burton Act handed out blueprints for community hospitals and said, “We’re gonna give you funding and you’ve gotta build this hospital”. And so, what that did is it standardized not just the way that we treat mothers in maternity care but it also standardized maternity care itself. All of a sudden it’s very difficult for mothers to room‐​in with their babies, it’s very difficult for women to avoid the assembly line approach to maternity care which says, “You labor in this room, and then you get moved to this room for recovery, and then you get moved over here.”

17:17 Lauren Hall: And even in my births in 2012, was the first time I gave birth, I was moved around during labor, like a sort of… Almost like on a conveyor belt, right? You start in triage and they do a bunch of stuff to you in triage, and then they move you to this room where you can labor, and then as soon as you have the baby you’re moved to this other room. I mean it was really, really bizarre. And that is largely a function of the way that we designed these hospitals in the Hill‐​Burton Act. And the centralized nursery taking infants away from their mothers, that was all part of this idea of making the hospital as efficient for staff as possible.

17:55 Trevor Burrus: I knew we could blame the government for so many things, but I did not know we could blame them for the baby room.

18:00 Lauren Hall: Yeah, yeah.

18:01 Aaron Ross Powell: So, was that the motivation then behind the Hill‐​Burton Act? Just an attempt, “We’re gonna pass a law that will make hospitals be constructed in a more efficient way”, or was there more to it than that? ‘Cause it just seems odd that… It’s never odd, the government is all sorts of things that seem odd but does them anyway. But it just seems odd to say like, law makers get together and say, “We are going to plan the uniform architecture of hospitals”.

18:29 Lauren Hall: Yeah, no, no, the motives I think were good, in the sense that what they were really trying to do is bring hospital care to rural communities and some urban communities that didn’t have community hospitals. So the goal was, “Let’s dump a bunch of funding into building hospitals”. It was also, Paul Starr, makes this point in his sociological overview of hospitals and American health care overall, it was also meant to be a jobs program. So the idea was, “Let’s get people to work, and building stuff that we need,” I.e hospitals. And, as he points out, there was this expansionary bias to the program which was, “We’re just gonna keep needing all these hospitals”, and once you have something as expensive as a hospital built, you’ve gotta use it, you’ve gotta figure out how to get patients in the door. And so that actually started… So in addition to standardizing care it also ended up really centralizing care, because you had to start pulling patients into these hospitals to get them used and to get them, to make sure that they remained profitable. But the original intention really was to bring health care to populations that did not really have as much access and to get people to work building this infrastructure over that period of time.

19:47 Trevor Burrus: My mom grew up in a small town in Northwest Oklahoma that had one of these hospitals put in there, which helped the town a lot. And I remember going that hospital, it does have a very interesting look to it. Now, in addition to hospitals we have funding, which is a major source of a lot of problems in American healthcare. The third party payer problem, whether it’s insurance or Medicare or Medicaid, the patient is not the customer. But this also has helped contribute to this medicalization of birth and death, correct?

20:19 Lauren Hall: Yes, absolutely. So, we have some interesting biases within the payment framework. For both birth and death, practitioners, providers, are reimbursed at much higher rates for medical interventions than they are for the communication with the patient about what their preferences actually are. So when I had an obstetrician for my first pregnancy, my appointments with my OB lasted less than five minutes. I had less than five minutes of face time with her throughout my pregnancy to talk to her about what kind of birth I wanted. And it was no surprise that when I actually asked her at about 16 weeks, like, “Should we talk about a birth plan or something?” She sort of just dismissed and she said, “Well we’re superstitious about birth plans. They don’t go the way that we want them to go usually”. And so I looked at that as a political scientist and I said, “Well this is someone that just doesn’t care about my preferences, right? If you just don’t care then that’s fine, but I wanna know that”. So I ended up switching to a family practice doctor who delivered babies at the hospital, and that was a much more positive experience. But the economic incentives were clear, my OB did not get reimbursed very well at all for prenatal visits.

21:35 Lauren Hall: She certainly did not get reimbursed for answering extra questions that I had. She didn’t get reimbursed if those appointments went over time, but she did get reimbursed for C‐​sections, for inducing labor with Pitocin or other kinds of mechanical means. So, she got reimbursed for doing medical stuff to pregnant women. And that’s great if you have a medical condition in conjunction with your pregnancy, it’s not great if your goal is to have a non‐​medicalized labor and delivery.

22:09 Trevor Burrus: That’s true for both government‐​paying and private insurance, it’s all kind of the same in terms of what Medicare and Medicaid will pay for. And also, is it the case too, when it comes to death, is it they’ll be paying for medical interventions, but also they don’t wanna pay. So, if you wanted palliative care and say, “Okay, I’m done with treatments, I’d like to die in a good way”, why wouldn’t they wanna pay for that if it’s cheaper?

22:38 Lauren Hall: Yeah, so the question I think is… So, when I talk to palliative care physicians about this they’re always very careful, because they obviously have to work with other physicians. [chuckle] I think there’s a couple things going on. One is that if you’re not trained in palliative care, if you’re an oncologist, for example, you have a lot of professional and personal pride in keeping people alive. And in most hospitals, palliative care is an opt‐​in consult, meaning that the patient has to know that palliative care exists and has to ask for it. So even if the insurance companies would rather the patient use palliative care as part of their treatment, it’s not always an option, given the other institutional barriers to accessing that service. The other thing is that it’s not always clear what economic direction palliative care is gonna move towards.

23:34 Lauren Hall: So, the actual evidence on palliative care, and hospice in particular, is that it’s probably cheaper for most kinds of illnesses, but not cheaper for some. So, there are certain kinds of illnesses, like if people live a very long time then hospice and palliative care do become more costly. So the insurance industry I think is still in a very uncomfortable situation where it doesn’t want to make enemies of oncologists and other kinds of traditional providers at the end of life. There are a lot of insurance companies though that are exploring using palliative care, for example, as a standard consult any time anyone is diagnosed with a life‐​threatening illness, simply because it can… It generally always improves outcomes, in terms of quality of life. It may reduce costs, but that’s a little bit less clear at the end of life. It’s very clear at birth, or during birth.

24:38 Aaron Ross Powell: Given that people… I mean, we’ve just been discussing people respond to incentives, and so it sounds like the current incentive structure for hospitals and doctors and payers pushes them to avoid palliative care and keep doing medical interventions to keep people alive, even if it’s not the best thing for them. So ideally we’d like to push back on that and have a more balanced thing, but how do we do that in a way that doesn’t risk pushing things in the other direction? Because you can imagine a situation where if the incentive… So we discourage doctors from trying to save people at all costs. We figure out some way to push back on that drive that the physician has keep his patient, but we don’t want them to be two blase about keeping people alive. And we don’t want a funding thing that encourages instead spending on palliative care as opposed to life extension care, because we don’t want insurance companies deciding more than they should, “Ah, we think we should just give up on you”. And so it seems like there’s a high risk of given the complexities of the incentives, there’s a high risk of the pendulum swinging too far the other way.

25:54 Lauren Hall: Yes, yeah. And that’s actually one of the concerns that a lot of patients… At the end‐​of‐​life, one of the issues I think you do have is patient demand and family demand, because patients don’t wanna give up hope. And the way that the Medicare hospice benefit is structured is actually a terrible incentive, because what it does is it requires you to give up any kind of curative treatment in order to qualify for hospice. So if you’re a patient that has any hope that you might survive this, you have no incentive at all to go on hospice, because of course you’re gonna fight till the end, right? So the Medicare hospice benefit actually sort of built into the system this really problematic incentive that keeps people in active treatment even when a combination of active treatment and something like palliative care would be much more beneficial for them. But this comes up in patient conversations all the time, and I was interviewing a palliative care nurse practitioner for example, who was talking to a black family member of a patient of hers and he just sort of pulled her aside and said, “Can you promise me that your recommendation isn’t to save money?” And she was heartbroken, right?

27:11 Lauren Hall: She’s a palliative care practitioner, she loves… I mean, part of the reason that she went into this incredibly emotionally draining field is to try to help people figure out how to die in a humane way that’s consistent with their preferences. And this guy had this very sensible question, right? Like, “How do I know you’re not just trying to profit the insurance company?” So that, I think, is a real fear of a lot of patients but it’s also a serious concern, I think, as you point out, on the incentive side. The best approaches that I’ve seen to dealing with this are situations where you have a collaboration between palliative care, you see this sometimes in oncology clinics, where you have palliative care physicians who work with oncologists. So it’s collaborative. And they also, in some of these situations, they do some cost sharing. And so they actually pool some of the funding that they get for these various kinds of treatments and things into a sort of general fund. And so that takes some of the… Instead of pitting palliative care physicians against oncologists, or pitting the insurance company against oncologists and in favor of palliative care or something, you actually have the different positions, working really closely together.

28:29 Lauren Hall: And I think that takes away at least some of the potential for abuse, because you have different physicians operating as kind of watch dogs on each other. The oncologist isn’t gonna let some palliative care guy come in and say, “Just give up chemo, it’s gonna save you”, if he actually thinks there’s the potential for someone to be saved. And the one example of this that I’ve seen, it’s not specific to palliative care but Grand Junction, Colorado did something similar when they were trying to reduce hospital admissions. And what they found is that, there’s actually a sort of Elinor Ostrom kind of lesson here about common pool resources, but what they found is that if you allow physicians to sort of informally monitor each other and you set up the systems for people to sort of keep an eye on each other and then you pool these resources in what people agree is a relatively fair way, you can actually get some pretty considerable cost savings as well as much higher quality care. So the way that we’ve siloed out medical care into, “You get treated by an oncologist until there’s no hope, and then we put you to the palliative care people to clean up the mess”, right?

29:37 Lauren Hall: And that’s what a lot of palliative care physicians feel like happens, is that they get the cases at the very, very end of life when quality of life is not as much of a question, where as if they could be more involved a year before they would be able to help people manage the symptoms that come along with chemotherapy, they would be able to help them with comfort care and making sure that their families are clued in, and having these really complicated conversations about end of life wishes. But when they’re called in the week before the patient dies, that’s not doing anyone any good.

30:10 Trevor Burrus: Years ago, midwives were very common. I don’t know what percentage of births, but, well most birth were in the home, I think in 1900, and with probably midwives. And now I think midwives are a little bit on the comeback, but I remember maybe 20 years ago it was… I remember a friend of the family decided to have a midwife birth and there was a lot of… Like, “Are you crazy?” kind of things. And I think Brooklyn hipsters are probably pretty into midwives, and maybe that’s one reason why it’s coming back, but what happened to midwives, and are midwives effective too. Are they a good substitute?

30:49 Lauren Hall: Yeah, so I’ll answer the second question first, which is “Are mid‐​wives effective?”, and the evidence suggest yes. There’s a lot of European countries that have what I think is the most effective system for giving birth, which is essentially a very commonsensical triage situation, right? If you’re a low‐​risk woman with a low‐​risk pregnancy you start out with a midwife. If any risk factors emerge over the course of that pregnancy you get a physician involved. If it gets really risky then you get a maternal‐​fetal specialist, who’s someone who specializes in very risky pregnancies. So, it’s not like we don’t know how to do this. Lots of other countries do this, and there’s actually hospitals in the United States that do this with midwives too. The evidence on nurse midwives is very, very positive. So, nurse‐​midwives are midwives who have a nursing degree and then they go on for a Master’s in midwifery. So they are advanced practice nurses, they have the medical chops to handle a lot of different emergencies as they come up during labor and delivery, but they won’t, given their scope of practice, they won’t handle very risky deliveries. So usually they will hand off uncontrolled gestational diabetes, or if you have preeclampsia, which is high blood pressure, during pregnancy, dangerously high blood pressure during pregnancy.

32:13 Lauren Hall: Many mid‐​wives, and some of this is regulated also, so in many states mid‐​wives can’t attend twin or multiple birth, triplets. But for the average woman, nurse‐​midwives have actually better outcomes than physicians, depending on how you look at those outcomes. So, midwives have much lower intervention rates, much lower C‐​section rates and overall the patient happiness with their mid‐​wives seems to be very, very high. At least comparable, if not exceeding that, of patients with obstetricians. The picture is a little bit less clear for certified professional midwives, or direct entry midwives, and those are midwives who come into midwifery through an apprenticeship program, so they’re not trained nurses usually. And their regulatory situation is much more complicated for those kinds of nurses. Some states license them, others don’t. Some they’re sort of explicitly illegal, others there’s just this sort of legal gray area. So, certified professional midwives, there’s a much wider variation in practice patterns. And so what we find, especially in home births, and certified professional midwives are, as far as I know, not allowed to practice in any hospital in the United States. So they exclusively attend births at birth centers or at home. And births with those midwives is a little riskier, for a variety of reasons that we can talk about.

33:41 Lauren Hall: So, you do have higher, a little bit higher, infant mortality with those midwives, but it’s still a very low… I mean, infant mortality is still very rare in this country, even with certified professional midwives. But there is a slight increase in risk with that type of midwife. So yeah, did you wanna follow up? Sorry.

34:01 Aaron Ross Powell: Just what do they do? If you’re doing a home birth. Over the months leading up to the pregnancy, we can look for risk factors, but what do they do if something unexpected happens and they can’t whisk you down the conveyor belt to the OR?

34:17 Lauren Hall: Yeah, so there’s a couple things that they can do. First of all, a lot of home birth midwives carry Pitocin, which is a synthetic form of Oxytocin. It can be used to induce labor, but in this case it’s actually used to prevent hemorrhage or control hemorrhage. So, what Oxytocin does in the uterus is it actually causes uterine contractions. And so if you have a woman who is bleeding uncontrollably, you can carry this Pitocin with you, it has very few side effects outside of the… It’s a pretty safe medication, and so even non‐​nurses can administer it in a safe manner. You give the woman a shot of Pitocin, that helps for uterus clampdown on the hemorrhage long enough for you to transport her to a hospital.

35:07 Lauren Hall: So, in all of the cases, what we’re looking at is, the goal of a good midwife is to assess the risks of the patient in front of her and transfer her to a physician or a hospital if those risks exceed what is compatible with midwifery. But midwives also have a variety of tools to handle those unexpected emergencies as they come up, and this is why midwives will check your… In a home birth they will check your blood pressure frequently, to make sure that you’re not developing preeclampsia, they’ll look at swelling to make sure that the swelling is normal, they’ll look for any abnormal signs… Fever, for example, is an automatic transfer to a hospital. And all of these different things. And the vast majority of birth injuries and birth… The major causes of maternal and fetal mortality are things that leave signs.

36:00 Lauren Hall: So it’s actually pretty rare for a woman to just die for no reason in child birth. There are usually warning signs ahead of time that a well‐​trained midwife can easily recognize and make that decision to transfer. So, I think one of the weird misconceptions that we have in this country about midwifery care is this sort of idea that if you get a home birth you’ve cut yourself off from medical care altogether, right? Like you’re just stuck with that mid‐​wife, even if you die. And that’s just not the case. If you talk to home birth midwives, they consider it one of their most important duties to figure out when something is outside the scope of their professional competence and get women to hospitals. Most midwives have physicians on call, so if there is something that’s a little bit off they can call that consulting physician and see if that’s something that needs to be… That they need to go in for, or if it’s something to just keep an eye on.

36:58 Lauren Hall: So, in an ideal system, you would have that collaboration between physicians and midwives in the same way that you would ideally have collaboration between palliative care physicians and oncologists. But unfortunately, the regulations work in such a way as to actively prevent that collaboration. And so the result is that women are less safe in the US system than they are in systems like Canada or the UK where midwives are actually incorporated into the healthcare system and you can have that open collaboration between mid‐​wives and physicians.

37:30 Aaron Ross Powell: I assume that midwives carry liability insurance, just as physicians do. Do they suffer the same sorts of incentives problems with theirs that pushes them into risk aversion or things that they shouldn’t necessarily be doing?

37:46 Lauren Hall: A lot of midwives do not carry malpractice insurance, particularly certified professional midwives. The vast majority of nurse‐​midwives operate in hospitals, and they are either covered under the hospitals malpractice insurance or they’re required to carry their own. So nurse midwives are a little bit different, because they have to work within the institutional constraints of the hospital. Certified professional midwives though, it’s a lot more interesting. They get to choose. Some states do require insurance coverage, I believe, but a lot of them don’t. And so it’s up to the midwives to decide whether they wanna handle that insurance or not, and a lot of them simply say that they don’t.

38:29 Lauren Hall: Now, in general, home birth midwives, even those who have malpractice insurance, say that the incentives don’t work quite the same way with them because they have closer relationships with their patients. And so the theory goes that midwifery patients… And I haven’t been able to find any hard data on this, but I suspect that it’s true anecdotally, is that a lot of midwifery patients, or midwifery patients generally, are less likely to sue, because they have a more trusting relationship with their midwife. So, if you look at a lot of the reasons that people sue for malpractice after births in hospitals, it’s actually because they don’t know what happened. So people are suing for information first and foremost, and in order to get the hospital records released, in order to get staff interviewed, you have to have an active lawsuit. So that’s another sort of problem, where there’s an incentive to sue in hospitals and not as much of an incentive to sue in the home birth context.

39:26 Trevor Burrus: So, what happened to midwives? In terms of the decline at least, or the use of it, we talked about some of them, there’s also licensing issues involved. And that could possibly tie into something you briefly mentioned with the Certificate Of Need laws when it comes to something like a birthing center where midwives might work but might not exist because the government doesn’t let it exist.

39:49 Lauren Hall: Yeah, so the destruction of midwifery was a very explicit and pretty well planned out campaign by physicians. So there’s actually some evidence, if you look at the Journal of the American Medical Association in 1912, I think, is one article where they talk about the fact that they can’t make any advances in obstetrics because midwives are hogging all the material that they need. And of course, “material” in this case is women’s bodies. And so essentially what happened was that physicians used state medical associations to lobby for increasingly restrictive regulations on the practice of midwifery. So what you had were midwives who were largely apprenticeship‐​based, they had no formal medical training, and so essentially what physicians did is they started prosecuting them for practicing medicine without a license. And they really ramped up these prosecutions in the early part of the 20th century, and the goal was to get women into hospitals where you could start doing the sort of scientific study of birth and start actually controlling the process in order to see sort of how birthing would be better. The irony, of course, is that at this time many physicians had higher maternal mortality rates than midwives because they were constantly sticking dirty hands and dirty tools and all sorts of awful things into women’s body.

41:24 Lauren Hall: They were intervening all the time. And if you don’t have a decent understanding of germ theory you are going to kill a lot of women. And so the largest cause of maternal death at this point is… At the point that we’re talking about in the early 1900s, is infection. And many, many of those infections were caused by physician hygiene issues. So, there’s one case of a midwife named Hanna Porn in Massachusetts who was prosecuted multiple times for practicing medicine without a license. And the physicians who testified are at trial had worse maternal and infant mortality statistics than she did. She was objectively a better provider than the physicians who were trying to get her out of practice. And they succeeded, so she was eventually booted from practice. What they noticed was an uptick, I like this this little detail, what they noticed is an uptick in birth certificates that were not signed, after her final conviction. And so what they conclude from that is that she continued to practice, because women trusted her, but she simply didn’t leave evidence behind.

42:38 Trevor Burrus: So, what about Certificate of Need laws?

42:41 Lauren Hall: Yeah. That’s actually the story in my state, New York, for why, for example, we only have two birth centers in the entire state of New York and Certificate of Need laws. So, the kinds of regulations that we were talking about with midwives are a way to control midwives directly through this licensing process. And I’ll just add very quickly, that this destroyed midwifery across the board but it had particularly awful effects on African‐​American women in the South. The granny midwife was not just someone who delivered babies, but she also provided this really comprehensive form of postnatal care to women who are having babies. And there’s a lot of evidence that the granny wives were very successful in lowering infant and maternal mortality, and the initial push was just to get them to boost their training a little bit. To teach them about hygiene, to get them to become sort of community health leaders in their capacity.

43:46 Lauren Hall: But then very quickly what happened, after a couple… After basically a decade, is that they started being targeted by physicians too, and so eventually granny midwives were made illegal in all Southern states, which meant that you lost all of these people who were able to give culturally competent care, who were able to work with people in really rural areas, people who had been really seriously harmed by the medical system who didn’t trust doctors, all of a sudden they have no option whatsoever.

44:17 Lauren Hall: So, the targeting of midwives was pretty comprehensive, but I think there’s a lot of evidence that it harmed black women more than white women, because black women just had fewer options. And then if you take into account the racism that black women experience when they went to hospitals. You have just astronomical, rates, for example, in Mississippi, of forced hysterectomies. So you go to the hospital in labor, a doctor decides that you have too many children and gives you a hysterectomy without your knowledge, or sterilizes you in some other way. And so, that procedure was actually common enough that it was called a “Mississippi Appendectomy”. So there were very strong reasons why women, why black women in particular, did not wanna go to hospitals to give birth. And yet the destruction of granny midwives meant that they were forced into these institutions that treated them in this pretty horrific way.

45:15 Aaron Ross Powell: Given all of the problems that we’ve discussed today, how do we go about changing things? How do we go about changing the legal incentives, the institutional incentives, particularly in the face of what I imagine is strong pushback from certain groups that have an interest in this, whether that’s the AMA or the insurance lobby or whomever else, what can we do?

45:40 Lauren Hall: Yeah, I try to be hopeful. [chuckle] The concern that I have, and the book ends on, is that we have a lot of compounding streams of different government policies that all point in the same direction. And so it’s just gonna be really hard to untangle at any one government level. I think there’s a couple things that… At the state‐​level Trevor mentions Certificate Of Need laws, I think at the state level we should absolutely stop allowing hospitals to veto the entry of competing organizations. It’s absurd to me that New York State, for example, has two birth centers because hospitals, every time that they try… Every time birth centers try to enter the market, hospitals just come along and they go, “Nope, we actually have maternity care totally locked in this area. It’s totally fine. We don’t need any new maternity providers”. And for some reason regulators go, “Oh, okay, that sounds fine”. Kentucky has zero birth centers, because every single birth center has lost their Certificate of Need battle. That’s just crazy, especially because the demand is very much there. So, I think pushing back against Certificate Of Need laws, I do think that more people and more women need to realize that a lot of regulatory issues are in fact women’s issues.

47:06 Lauren Hall: When I talk to people about the kinds of birth that they had, a lot of women’s responses were just, “Yeah, I mean, the world we live in doesn’t make any sense”. But what they didn’t realize is that it doesn’t make sense because specific people have invested interest in not making it makes sense. “It makes sense for them, but it doesn’t make sense for you”. And so I do think that telling… And if women became more aware of how their choices are artificially limited by these regulatory structures that very often serve the interests of physicians and hospitals, I think you’d get more outrage.

47:43 Lauren Hall: So, I guess there’s that. I think the biggest hope that I have is the reimbursement piece, because so much of this… Because states and the federal government are just so strained by escalating healthcare costs. I think we’re gonna see room made in the near future for more experimentation in healthcare delivery. And you’re already seeing some focus on community‐​based options as alternatives to these huge hospitals, but there’s a lot of institutional inertia. Once you create a giant medical center it’s very hard to make the case to local or regional officials that you need to cut back the use of that resource. You’re talking about people’s jobs, you’re talking about a major economic powerhouse in the region, and where I live in Rochester, the University of Rochester Medical Center is one of the largest employers in the entire region. So it’s really hard to decentralize once you’ve shoved all those resources into a huge infrastructure behemoth that you then have to keep funding and throwing resources at.

48:51 Trevor Burrus: We could also probably do something about the scope of practice, I think that’s important too, which has been pointed out about nurse practitioners can do a lot more now. The AMA is probably not a big fan of it, but I think there’s a emerging push along those lines.

49:04 Lauren Hall: Yeah, and there was actually some helpful stuff from both the government, but also some of the major health non‐​profits, where the physicians kept pushing back against nurse practitioners practicing independently. And finally, I mean, there were actually some major… I don’t wanna misname anyone, I don’t know which organization it was, but there were a couple of organizations that gave the AMA a kind of pat on the head and said, “We understand your concerns, but given the escalating cost of healthcare you’re gonna lose on this one”. So I think you’re starting to see the physician monopoly on a lot of these kinds of care, areas of care dissolving, because we have such a huge shortage of physicians generally, in a lot of areas. I mean, obstetrics is losing providers like crazy, in large part because of the liability crisis. But you’re also just gonna start seeing I think local and regional folks saying, “Well actually, there are these cheaper forms of care”.

50:07 Trevor Burrus: You talk about, in the book the principles that should guide reform and how we should be thinking about this, especially with birth and death. And it’s not just the Hippocratic Oath, if we re‐​conceptualize what these are and make sure that we treat people with respect and a lot of their dignity as human beings, and we could probably get somewhere if we change our thinking about these two events that either a lot of people go through and everyone will go through.

50:38 Lauren Hall: Yeah, so one of the frameworks, and I’m not a bioethicist, but I do think that the focus “Do no harm” has really done a lot of harm. [chuckle] In that there are other competing principles. So, there’s patient autonomy, which is where the principle of informed consent becomes so important. There’s questions of justice, “Who gets access to what kinds of care under what situations?”. And then there’s the question of… It’s not just, “Is the medical intervention that you’re doing on this person doing harm, but is it providing them any benefit?” And what we find is that a lot of the interventions that we do to the birthing and dying are not providing the benefits, they’re extremely costly, and they’re actually doing active harm.

51:27 Lauren Hall: And people aren’t actually consenting to these, because they don’t fully understand the range of options available to them. So, I guess part of what I wanted to do in the book is really refocus the conversation around the individuals who are doing this. Birth and death are incredibly vulnerable periods in anyone’s life. They are incredibly individual, they are extremely preference‐​sensitive, and those preferences have enormous impacts on the medical outcomes. And so we have to move away from a system that treats people as though they are sort of standardized objects on a conveyor belt, and we have to allow more freedom for people to make decisions that might be uncomfortable, that might mess with the standard of care in the hospital protocols, and the only way that we can do that is by loosening government regulation at all levels. Because what we’ve done is we’ve created this sort of regulatory web that pushes people into centralized hospitals to give birth and to die, and just all of the evidence that we have is that that’s not the best place for the majority of people. It might be a good place for some people, but we need to open up those regulatory bonds to let people make decisions about how they want to take on those really vulnerable and really meaningful tests of their life.

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53:03 Aaron Ross Powell: Thank you for listening. If you enjoy Free Thoughts, you can find our Free Thoughts discussion group on Facebook or on Reddit at R/​Freethoughtspodcast. You can follow us on Twitter at FreeThoughtsPod. As always, please rate and subscribe to us on Apple Podcasts, Spotify, or wherever you get your podcasts, Free Thoughts is produced by Tess Terrible and Landry Ayres. To learn more, visit us on the web at www​.Lib​er​tar​i​an​ism​.org.