I went into labor with my second baby when I was 39 weeks pregnant. However, it wasn’t until I was several hours in that I even suspected the discomfort I was experiencing was labor. It seems strange, but because my first baby was delivered via emergency c-section, I’d never experienced labor pain before.
When I called my doctor — a sole practitioner who’d been practicing for three decades — to let him know I thought I was in labor, he shot back, “I examined you yesterday. There’s no way you’re in labor.” (It’s true. I’d been in for a checkup the day before, and in that appointment he’d shared a few things with me. First, based on a quick glance at how I was carrying — and in spite of all the evidence suggesting I was an ideal VBAC (vaginal birth after Cesarean) candidate — another C-section was all but certain. And second, labor was not imminent.). During our brief call, he didn’t seem concerned about the pain I was experiencing, nor did he offer an alternate explanation for why I felt bad.
However, about an hour later, as the contractions became more intense and more regular, I called him again. I told him that I understood that he didn’t believe I was in labor but I felt badly enough that, regardless of the cause, I needed to see someone. It was almost dinner time on a Saturday night and he blew me off again. “Do what you gotta do Ellen. But I’m not going to the hospital tonight.” At my wits end with both the doctor and the pain, I turned to my husband and said, “Let’s go now. If we’re lucky, someone else will deliver this baby.”
A few hours later, my sweet baby Lyle was born via VBAC. My doctor never showed up.
I saw that doctor one more time at my six-week postpartum checkup. Neither of us brought up the phone calls before the birth or the fact that he didn’t deliver the baby. And when the checkup was over, I ignored his directions to stop at the front desk to schedule an annual. Instead, I sped past reception and headed straight home, determined to never see him again. It wasn’t until I became pregnant with my third baby that I re-engaged an OBGYN.
I often think about this experience when I hear the mountains of statistics about our country’s poor maternal outcomes. Most of us are aware that the U.S. has the worst maternal mortality ratio in the industrialized world. We’re also aware things are even more dire for black mothers, who are 2.5x more likely to die from maternity related causes than their white counterparts. Our poor performance has worsened since the pandemic, with the maternal mortality rate shooting up by nearly 20% between 2019 and 2020. Evidence shows these statistics do not reflect medical failures but failures in the system’s ability to listen to women.
This trend of dismissing women in clinical settings, or medical gaslighting, is not new, but we are getting better at documenting it. We now know that for a variety of conditions and diseases, including stroke, women are more likely to be misdiagnosed than their male peers.
When it comes to maternity, gaslighting is particularly dangerous because of the teamwork and level of trust that must be established between patient and provider to achieve the desired outcome. The polite, above-board relationship between you and your doctor has an expiration date. Eventually, you’re in the trenches working together, sometimes making split decisions. As a patient, you’re completely exposed. Your life and the life of your child are on the line. A successful outcome hinges on a functional give and take between you and your provider — an understanding that each of you will put your best effort into your respective roles.
Despite this collaborative dynamic, maternity care, like most other service lines, is centered around the doctor. We meet the doctor on his turf, he does stuff to us and tells us to do more stuff when we leave. If we don’t understand what he asked us to do or why it’s important, it’s our failure and we suffer the consequences.
The reimbursement structure further aggravates things. Maternity is paid out as a single episode and the reimbursement rate is low, meaning the provider gets the same cheap payment whether a patient sees him 12 times during a pregnancy or 30. A typical health system either loses money or just breaks even on its Labor & Delivery services. As a result, there is little incentive or budget to invest in innovating around or improving the experience.
Yet despite the poor economics, health systems consistently point to Women’s Health as a top strategic priority. Some have rich neo-natal units that offset the losses on maternity. Others cite the fact that women make 80% of their family’s healthcare decisions and view maternity as a critical opportunity to bring women and their families into the system.
So, taken together, we have this perfect mess: a service line that is strategically — but not financially — significant, and poor outcomes that are shamefully defined by a racial divide.
If there is any good news in this mess, it’s that there are real options for improvement that, net-net, do not cost more money. In fact, if implemented thoughtfully, they stand to lower the total cost of care.
First, it’s time to talk seriously about increasing the number and expanding the role of midwives. For most pregnancies, a midwife is a perfectly qualified, if not superior, clinical partner. The spectrum of midwifery includes everything from fetal heart detection to delivery. In addition, midwives are trained in a human-centered approach to care which over-indexes on listening to the patient, understanding her situation and concerns, and capturing barriers to success – social or otherwise — that physician training simply does not emphasize.
Second, we need to take stock of the ways in which digital offerings can empower women. This may mean exploring the ways in which remote patient monitoring (RPM) can be used to manage and inform patients and providers in between appointments. Not only does RPM enable earlier detection of serious conditions like preeclampsia, but many women say that it provides them with a sense of agency and increases the overall level of trust they have in their providers. Beyond RPM, we need to think about other ways we can leverage digital capabilities to expand access, improve quality, and empower women. Examples include, but are not limited to, tele-lactation, tele-therapy, serving up high-quality maternity, postpartum, and family content, and facilitating social connections between moms and with community-based organizations. These forms of digital support are either relatively low-cost or they lead to cost-of-care reductions that far exceed their cost.
Ultimately the future of women’s health lies not in a deeper understanding of the science of our bodies, but in our willingness to promote people and cultivate environments that allow us to be seen and heard.