In India, as in the United States, those facilities that are better at achieving the right balance of interventions rarely share best practices with others. In India, as in the United States, the biggest risk factor for getting an avoidable and potentially harmful c-section appears to be which facility a woman goes to for care, not her personal preferences or medical risks. The testimonies during the conference revealed a startling set of facts. In a recent Lancet commission on maternal health, 77 researchers from around the world, including me, concluded that our primary struggle in maternal health care is to find the appropriate balance – to provide the right patient with the right care at the right time. In many cases doing more can actually be harmful.Ī security device is shown on the right ankle of a newborn in the maternity ward at Medical City Hospital in Dallas, March 15, 2007.| Source: AP/Matt Slocum The balance between too much care and too little But simply advocating that we start to do more things may be inadequate. The principal way my profession aims to improve care is by issuing guidelines that spell out the things we should be doing more of. And in America, India, and many other countries, the standard approach to address these challenges is similarly limited. Fundamentally, providing too little care too late or too much care too soon are challenges that all maternal health systems are confronting, including the American system. Higher rates of chronic and infectious diseases, higher rates of illiteracy, higher rates of abject poverty are all factors contributing to avoidable suffering in childbirth.īut as I sat there, listening to case after case, aware of the differences between the American and Indian context, much of what I was hearing also sounded uncomfortably familiar. Indian women also have less access to basic social services than American women, though they are far more likely to require them.
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Nearly half of Indian women are married before the age of 18 and have limited capacity to make independent decisions regarding reproduction. Indian women often have less agency to advocate for themselves compared to American women. Throughout, I was conscious of the fact that Indian clinicians have different training and face different constraints than I do. Beyond instances of clinically measurable harm, the stories illustrated routine misappropriations of care that these women felt deprived them of basic dignity. Others were equally heartbreaking examples of women receiving too much care too soon – unnecessary inductions of labor, episiotomies and C-sections. Many were heartbreaking stories of women receiving too little care too late – failures to provide antibiotics, blood and other forms of resuscitation in a timely way. The meeting began with Indian women describing their experiences of care gone wrong. So I got on the long flight from Boston to Mumbai. Over 200 activists and scientists, midwives and physicians, journalists and attorneys planned to discuss strategies to advance justice, dignity, and respect for pregnant women. Still, the opportunity to scrutinize my profession alongside international experts from a broad range of disciplines was compelling. I initially hesitated when I received an invitation to speak at a human rights meeting. But these are not things I have deep experience with.
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I’ve read about the gender-based violence, the profoundly disturbing cases of disrespect and abuse that too many women in India and around the world experience. I take care of patients in at a well-funded teaching hospital in Boston, where pregnant women seem well-respected and have clear, inviolable rights. But a trip to India for the 2017 Human Rights in Childbirth meeting led me to a humbling realization: when it comes to childbirth, both countries fall short in surprisingly similar ways. I long assumed that our most puzzling American health care failures were idiosyncrasies–unique consequences of American culture, geography, and politics. Nonetheless, Texas babies still have a lower survival rate than New Mexican babies. Texan obstetricians, when compared to their counterparts in neighboring New Mexico, are 50% more likely to intervene on the baby’s behalf by performing a cesarean section. In childbirth the relationship between more and better is complicated.
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In medicine, providing more care is often mistaken for providing better care. The reasons we fall short are not obvious. Our health outcomes, from mortality rates to birth weights, are far, far from the best.
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Our way of childbirth is the costliest in the world. After eight years of practicing obstetrics and researching childbirth in the United States, I know as well as anyone that the American maternal health system could be better.