“Let me give you some basic facts,” Republican Senator Ted Cruz began, his eyes twinkling at the healthcare truth bombs he was about to unload on his poor, unprepared colleague Bernie Sanders, during CNN's Affordable Care Act debate last night.
Cruz explained there was a simple reason that medical care in the United States costs more than it does in the U.K., France or Germany: “We get a lot more and a lot better,” he said. Then looking to his prepared—and, one would assume, researched—remarks, Cruz began rattling off the medical procedures that make America so superior.
“The United States, population controlled, delivers three times as many mammograms as Europe, two-and-a-half times the number of MRI scans, and 31 percent more C-sections. We provide more health care.”
A senator from a state where pregnancy-related deaths have doubled in recent years thinks that our incredibly high rate of cesarean sections is an indicator of American medical superiority. But in fact, the ideal rate for women and their babies is around 19 percent, according to a recent analysis in The Journal of the American Medical Association.
Ignoring that Cruz muddled his “facts”—the U.S. does not provide 31 percent more cesarean sections than Europe, though around one-in-three births in the U.S. come through surgery compared to one-in-four in the UK—the very notion that more caesareans equals better health care is astounding in its ignorance. In actuality, our high rate is an indicator of the high cost we pay for inferior outcomes.
“Cruz has confused doing more with doing better,” Eugene Declercq, a Boston University School of Public Health professor and a CDC statistician, told The Daily Beast.
It’s the outcomes, not the procedures, that should be used to judge the quality of care, Declercq said, noting, “It’d be better if we took some of the money we spent on C-sections and put it in prenatal care.”
Declercq makes an important point. Our maternal mortality rate is a national shame. While countries around the globe—including Iran, Vietnam, Russia and Romania—have seen maternal death rates plummet, the United States has bucked the trend and moved in the opposite direction. U.S. mothers died in 28 per 100,000 births in 2013, up from 23 in 2005, according to a research group from the University of Washington. More mothers die from pregnancy-related complications in the U.S. than in the UK or France or Germany, or Finland, or probably most of the other countries Cruz thinks provide inferior maternal care.
Despite the high C-section rates in Cruz’s home state of Texas, it also has the highest rate of maternal mortality in the developed world. And driving that disgraceful statistic are black women who make up 11.4 percent of all pregnant women in the state, but account for 29 percent of the maternal deaths. Ironically, these are the very women who are more likely to have a C-section, said Marinah Farrell, a practicing midwife who operates a free clinic in Phoenix and is the president Midwives Alliance of North America (MANA), a professional organization for midwives.
“When people like Cruz talk about this C-section group they're often talking about [a] privileged group instead of the women who are part of a vulnerable population that doesn’t have a choice,” Farrell said. “It’s the more vulnerable women who are subject to systemic abuses and interventions in their births that are not leading to better outcomes.”
The American Congress of Obstetricians and Gynecologists announced a number of steps in 2014 as part of an overall plan to reduce the nation’s cesarean delivery rate in first-time mothers. And the Department of Health and Human Services has a goal to bring down cesarean births rate for low-risk women to 23.9 percent. For women who have previously given birth via caesarean, the goal is 81.7 percent.
Now why would that be?
In the last 20 years, the cesarean rate has increased some 60 percent. The reasons behind the climb are myriad and include increased dependence on technology, arbitrary physicians’ policies, fear of negligence lawsuits, and as Cruz notes, the private insurance norm of fee-for-service billing by which most hospitals operate that incentivizes C-sections.
While necessary cesareans are life-saving procedures—on this, everyone agrees—when the rates get to around ten or 15 percent, medical experts say the reductions in maternal and newborn mortality rates stop. C-sections come with the risk of serious complication like hemorrhage and infection as well as post-partum difficulties including harder recoveries and depression.
And once a woman has a C-section, she’s almost assured to have subsequent births that way. Yet the American Congress of Obstetricians and Gynecologists has called vaginal birth after cesarean (VBAC), “a safe and appropriate choice for most women who have had a prior cesarean delivery.”
“Unfortunately women hear messages from politicians and doctors and other parents that say VBAC is dangerous,” said Jen Kamel, a mother who gave birth via VBAC and now runs an education and advocacy website devoted to the issue.
“But we have science behind us,” Kamel said.
Last night, Cruz finished his factually-inaccurate point with a plea to keep government out of our health care. “Whenever you put government in charge of health care, what it means is they ration. They decide you get care and you don't.”
But a large section of U.S. women who receive unnecessary cesareans—many of them represented by Senator Cruz—lost those choices long ago.