This is third and final part of an ongoing series on maternal health care from Rachel Bruns.
Iowa families navigate a challenging maternal health environment including a rise in unnecessary C-sections that are primarily driven by provider and hospital finances and maternal health policy that makes it difficult to receive care from providers with the best outcomes. When patients experience decades of ignored research, coercion or lack of informed consent — trust in the entire medical system and public health suffers.
How birth experiences shape confidence in medicine
An area I didn’t expect to speak out on is the continued harm caused by Iowa hospitals and clinics in how they are performing nonconsensual and often illegal drug tests on mothers and babies – leading to false positives, inappropriate intervention from Iowa’s child welfare program and further reducing trust in medical care.
There has also been an increase in unassisted births (also known as freebirth or wild birth) – with some families opting into giving birth without support from a midwife or physician. It is important to note that “freebirth” is not the same as homebirth, as a homebirth by definition would include a trained provider – such as a midwife who can manage emergencies including neonatal resuscitation and postpartum hemorrhage and would have skills to manage breech or shoulder dystocia.
The rise of unassisted births is a symptom of growing mistrust in medicine – and also the challenges families face in their ability to afford out-of-hospital based care in states like Iowa that do not provide adequate reimbursement to providers for the more than 40% of births covered by Medicaid. I have spoken to pregnant Iowans who felt they had no choice but to have an unassisted birth. They were traumatized by a previous hospital birth and refused to go back to a hospital, but couldn’t afford an out-of-hospital birth with a trained provider without Medicaid or insurance providing adequate coverage.
Families wanting out-of-hospital experiences should not have to have the false choice of either paying out-of-pocket for care with a midwife or going to a hospital, where they may be exposed to illness, will have no child care options, previously experienced obstetric violence or can’t find a provider who will support their birth choice to forgo surgery. These false choices lead people to be more easily persuaded by influencers profiting off people’s desire for autonomy.
Trust issues from two sides
We are in a challenging environment with families having to navigate what is trustworthy from both “wellness” influencers and public health leaders. I sympathize with medical professionals like Dr. Rebeccah Diamond, a pediatrician, who writes about the struggles working in this environment – simultaneously pushing back on misleading health information and working to make the health care system better:
“I now fight on two fronts. I fight medicine’s real failures — because they are real, and they matter. And I fight the damage done by pseudoscience dressed up as rebellion. I defend vaccines, evidence, and cause and effect, while being told I am protecting an establishment I have spent my career challenging.”
The most recent Iowa Maternal Mortality Review report (covering 2019-2021) found that 95% of pregnancy-related deaths in Iowa were preventable and 30% of those were due to infection, driven by pregnancy-related COVID-19 deaths of unvaccinated women. While the report covered the height of the COVID-19 pandemic, the reality is pregnant women are still at a higher risk of developing complications related to COVID-19 infections and there is new research showing the negative impacts of COVID-19 infection on the child’s development. Most medical maternity care providers follow professional association guidance and encourage vaccinations during pregnancy.
At the same time, many of those same providers are ignoring those same professional association guidance documents on topics such as VBAC, maternal levels of care or informed consent. This hypocrisy of only adhering to the guidance that fits the preference of a provider further complicates patients’ trust in medical providers and institutions. Ideally providers are informing their patients of all their options and associated risks/benefits – and whether it is on vaccines, surgery, inductions or otherwise, the provider should respect and facilitate care in alignment with the patient’s decision.
The top reason for hospital admissions in the United States is not because someone is sick – but to give birth. At the same time, approximately six out of 10 people across the globe have experienced some form of obstetric violence, which can include bullying, forced surgery, nonconsensual cervical checks and being forced to lie on their back during birth.
If state and health care leaders want to see improved confidence in the medical system, the place they need to start improving care and culture is where families experience the most harm and exposure to the medical system – at birth. The evidence is clear. The solutions exist. What’s missing is the will and leadership to implement them.
Rachel Manuel Bruns is a volunteer maternal health advocate and lives in Des Moines with her partner and two children. If looking for support on pregnancy, birth and postpartum support check out her compilation of maternal health resources. Rachel can be reached at rachel.m.bruns@gmail.com.
