Tuesday, February 5, 2013

Unintended consequences of "pregnancy prevention"

A provocative essay published a few days ago in the Wall Street Journal argued that America's falling fertility rate (which the author called the "baby bust") will make it difficult, if not impossible, to address challenges of anemic economic growth, an immense federal budget deficit, and the care needs of an exploding population of retiring "baby boomers." This piece has already inspired a good deal of back-and-forth debate - one columnist, for example, labeled it "a bunch of baloney" - and I don't intend to adjudicate that debate here. However, it is ironic that as a national conversation ensues about the pros and cons of having fewer children, the Obama Administration is struggling to placate religious and other employers which have objected to the Affordable Care Act's provision that requires them to provide and fully finance medications to prevent pregnancies.

Full disclosure: I am a practicing Catholic and father of three children. And I don't believe for a moment that our President intended to wage a secular "holy war" against institutional Catholicism, any more than I subscribe to the bogus liberal myth that faith-based groups that have moral qualms with hormonal contraception are bound and determined to block non-believers from accessing it.  (If that was really the case, they'd be leading boycotts of Target and Walmart, which both sell a month's supply of birth control pills for $9, according to the Reproductive Access Project.) But the overheated rhetoric about what some simply term "the HHS Mandate" has, in my mind, obscured a critical point: "pregnancy prevention" is vitally different from the prevention of diseases.

The Department of Health and Human Services web page that summarizes preventive services covered by the ACA covers long list of conditions that no one would ever want or wish on their worst enemies: cancer, heart attacks, strokes, hip fractures, diabetes, depression, and a host of infectious diseases. And then there's pregnancy. "Unintended" pregnancy, to be sure, but its inclusion should be a bit jarring even to health advocates who believe that delaying or declining childbearing is associated with health benefits. But when the Institute of Medicine's Committee on Clinical Preventive Services for Women recommended that FDA-approved methods of contraception be called preventive, it effectively defined pregnancy as a disease.

Defining pregnancy as a disease to be prevented is not just a matter of semantics. I've written before about how an overly interventionist approach to pregnancy is largely responsible for the current U.S. rate of one in 3 babies being born by Cesarean section, and predictions that it may soon approach 50 percent. In most countries, prenatal care and labor are primarily managed by midwives - pregnancy generalists, if you will. In the U.S., most pregnant women are instead attended by obstetrician-gynecologists: specialists in surgical delivery. Imagine if every person with garden-variety back pain was advised to seek care from a spine surgeon, or every person with a sinus infection first consulted an otolaryngologist. Would you be surprised if the result was many more back and sinus surgeries? A recent article in Harvard Magazine encapsulated this problem of perspective:

Risk perception and tolerance help determine professional standards of care, influence hospital protocols, mold the media’s telling of stories, and even influence laws. All these forces interact in complex ways. ... Saying that a certain percentage of C-sections are unnecessary is fairly simple. But weighing risks and knowing whether surgery is necessary in a particular case—or even whether a surgery was necessary in retrospect—is much more complex, and fraught with emotion. The obstetrician sees C-sections as generally safe, and if the outcome he or she wants to avoid is dire, even devastating—such as a baby’s becoming stuck and deprived of oxygen, which could lead to cerebral palsy—why wait to find out what will happen, however unlikely that outcome may be?

Make no mistake, a zero percent rate of C-sections is neither achievable nor desirable. A small proportion of pregnancies are complicated by health risks to the mother and baby, and interventions are necessary to prevent bad outcomes. But much lower Cesarean rates can be achieved without sacrificing safety, simply by approaching pregnancy as a normal, healthy condition, rather than a disease. A recent study in the Annals of Family Medicine reported a 4 percent Cesarean rate and 95% successful VBAC (vaginal birth after Cesarean) rate at a Wisconsin birth center for Amish women over a 17-year period, with no maternal deaths and a neonatal death rate similar to that of Wisconsin and the U.S. Lest this result be attributed to a miracle of Amish genetics, an Indian Health Service hospital in New Mexico where I spent a month-long elective during my family medicine residency attributed its 7 percent Cesarean rate to a conservative approach to labor (managed exclusively by family physicians) and cultural attitudes that favored vaginal deliveries.

We can agree that in general, unmarried teenagers should not be conceiving babies, and that a few pregnancies do expose mothers and infants to serious complications. But classifying contraceptives as preventive services and treating pregnant women as if they have fatal diseases is not a rational way to go about improving women's and maternal health outcomes.