This fall, my university nominated me as a candidate for the 2010 Harry S. Truman Scholarship award.  As just one part of the application process, I am required to submit a proposal for a societal problem that I would help solve with my graduate degree.  I plan to obtain a law degree with a focus on Health Law & Policy, and issues in women’s health will be the focus of my work.  Below is the proposal I have submitted to the Truman foundation.  I thought my birth junkie friends might find it interesting.  Excuse the brevity; the proposal guidelines require a maximum of 200 words in the “Problem” and “Solution” statements, and a maximum of 100 words in the “Obstacles” statement.  Editing myself to these parameters was certainly the most challenging part of this exercise.
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To: Kathleen Sebelius                    Office Held: Secretary, Department of Health and Human Services

From: Gina Crosley-Corcoran

Problem Statement:

The National Center for Health Statistics reports that the United States’ infant mortality rate is higher than “most other developed countries”[1].  Many maternal health experts cite our highly invasive obstetrical model of care as a contributing factor for our poor infant mortality score[2].  The World Health Organization stresses that a cesarean rate of 15% is “a threshold not to be exceeded”[3], yet the United States’ cesarean rate is an all time high of 31.8%[4].  These numbers indicate that we are failing to meet our goals for the “Healthy People 2010” initiative[5] set forth by the U.S. Department of Health and Human Services.  Studies have shown that we are performing too many cesareans, preterm births are at an all time high, and doctors prescribe many unnecessary interventions that may have lasting consequences for both mother and child[6].  While medical experts concur that vaginal birth is the safest option in normal, low-risk pregnancies, fewer women than ever are offered the option of a supported, natural birth.  Thirty percent of hospitals refuse to allow a mother a vaginal delivery after cesarean (VBAC)[7], even though repeat cesareans can be riskier to both mother and baby[8].

Proposed Solution:

To improve infant and maternal mortality rates, and close the widening gap in our “Healthy People 2010” objectives, the United States must safely decrease our cesarean and obstetrical intervention rates.  American women need greater access to Certified Nurse Midwives, freestanding birth centers, and trained labor support (doulas), which have been show to decrease the risk of cesareans and other invasive interventions[9].  These obstetric procedures often increase health risks to both the mother and child without improving birth outcomes.  Obstetricians need additional training to support natural, non-invasive birthing practices, while mothers deserve to choose their provider, birthing environment, and preferred birthing method.  All pregnant mothers, regardless of income, should receive quality prenatal care accompanied by childbirth education courses so they can make informed decisions regarding their own care.  Following the birth, mothers and babies need greater postpartum support, along with lactation education and services so they can both make the healthiest possible start.  Finally, we must hold accountable those hospitals and providers who institute unlawful VBAC bans, which bypass informed consent and patient autonomy.

Major Obstacles/Implementation Challenges:

Physicians admit to practicing “defensive medicine” and are quick to perform cesareans out of fear of liability[10].  Without a change in malpractice insurance, and a reeducation of obstetricians, the cesarean rates may continue to soar while doctors view surgical deliveries as the less litigious option.  Health insurance companies retain much control over services provided, and often greatly limit the scope of birth options available to both mothers and their care providers.  Without reform, providers may continue to use invasive procedures in low-risk women without medical indication or evidence to support such use.

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[1] MacDorman MF, Mathews TJ. Recent Trends in Infant Mortality in the United States. NCHS data brief, no 9. Hyattsville, MD: National Center for Health Statistics.

[2] Wagner, Marsden. Born in the USA How a Broken Maternity System Must Be Fixed to Put Women and Children First. New York: University of California P, 2008.

[3] World Health Organization, UNFPA, UNICEF, and AMDD. Monitoring Emergency Obstetric Care: A Handbook. Geneva: World Health Organization, 2009.

[4] Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2007. National Vital statistics reports, Web release; vol  57 no 12. Hyattsville, MD: National Center for Health Statistics. Released March 18, 2009.

[5] U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.Objective 16-9.

[6] Childbirth Connection. “Report Reveals Serious Problems in Maternity Care Quality and Value.” Press release. Http://www.childbirthconnection.org. 8 Oct. 2008. 2 Dec. 2009 <http://www.childbirthconnection.org/pdfs/ebmc-press-release.pdf>.

[7] “VBAC Policies in US Hospitals.” International Cesarean Awareness Network. 02 Dec. 2009 <http://www.ican-online.org/vbac-ban-info>.

[8] MacCorkle, Jill. “Position Statement: Elective Cesarean Sections Riskier than Vaginal Birth.” International Cesarean Awareness Network. 16 Aug. 2002. 02 Dec. 2009 <http://www.ican-online.org/vbac/postion-statement-elective-cesareans-riskier-than-vaginal-birth>.

[9] Sakala C. Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births? Soc Sci Med. 1993 Nov;37(10):1233-50. Review. PubMed PMID: 8272902.

[10] Hyer, Richard. “ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates.” Medscape Medical News. 12 May 2009. Web. 09 Dec. 2009. <http://www.medscape.com/viewarticle/702712>.