I had the pleasure of seeing Atul Gawande speak at the National Museum of New Zealand (Te Papa) a few weeks ago. He noted that in America, many people do not know who their doctor is. This made me chuckle. It reminded me of the many differences between the way health services are set up in American and New Zealand. I got pregnant with my first child in 2008, when I was at Yale as a visiting scholar. I had half my maternity care in America and half in New Zealand. The difference was striking. Yale was flash, high-tech, and at each appointment I had lots of tests and exams. My weight for example was diligently tracked. I was told gently that I had gaining far too much weight in the first trimester, and if I continued in this manner I would be at higher risk of complications in the third trimester.

I did a double-take when I first saw my mid-wife’s office in New Zealand. It had a small desk, two old office chairs, a bed, and a machine for measuring blood pressure – that was it. It was so simple, run down even, and I don’t think my weight was ever recorded, for that or any of my subsequent pregnancies. (For the record, I never had any pregnancy complications, weight-related or otherwise.) What I did have was my mid-wife’s direct cell phone number and permission to call her anytime. In New Zealand I have always known who my doctor is. Growing up I had one doctor until I was 21 years old (I still see her occasionally when my GP is not available). Since moving back in 2008, my husband and I, and now our three children, all have one doctor (who we seem to see weekly!).

I don’t think I had a primary care doctor in America. At least if I did, I didn’t know who it was, and I guess that’s the point. This led to some confusion. For example, I noticed that some of the skin products I was using for pregnancy related acne said not to be used during pregnancy (as does pretty much everything). I wanted reassurance but didn’t want to wait until my next scheduled obstetrician’s appointment. I rang Yale Health and explained the situation; they sent me to dermatology. The young dermatologist was flummoxed, and used his phone to look up the FDA category warnings. He read aloud that I should not be using these products and they will “harm my baby.” “How?” I cried, “In what way? What was the risk that harm had already occurred?” He didn’t know, and suggested I discuss it further with my obstetrician. I was distraught. It turns out (…we can skip the detail here…) that the products are actually completely fine. The baby was fine. It is just so hard to imagine something like this happening in New Zealand. Here, I would simply have emailed my doctor or texted my midwife. I would have had a sensible answer in less than 24 hours.
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When I left Yale, my colleagues were (from my perspective) surprisingly worried that I had turned down the prospect of another year long contract, that both my husband and I were at that stage unemployed, that instead of immediately looking for work we were planning to travel for 6 weeks before returning to New Zealand. But we couldn’t see anything to worry about. We would have free public health care in New Zealand, family to stay with, and we both pretty employable. Again, everything turned out fine. Many Americans are aware to some degree that their health system is expensive and efficient, but they don’t understand just how strange it seems from the outside, or what the alternatives might be. In New Zealand, access to good quality health services is not dependent on being employed. For me, with low-risk pregnancies, having a mid-wife with a slightly shabby office and a cell phone number I could call 24/7, was much more useful that all the high-tech gear available at Yale. Don’t get me wrong, it was kind of nice to be fussed over when I saw my Yale obstetrician. It was my first pregnancy. I liked the attention. But in retrospect, much of it wasn’t necessary. And in the end, the stress caused by that Yale dermatologist outweighed all the obstetric pampering.

This interesting article by Neel Shah looks the percentage of birth’s occurring in hospitals in America versus the UK and the rate of C-sections for low-risk pregnancies. Shah argues that nearly half of cesareans done in the U.S. currently appear to be unnecessary, and come at a cost of 20,000 avoidable surgical complications and US $5 billion of budget-busting spending annually. In New Zealand 81% of women are cared for by a mid-wife; 3% of women give birth at home, 10% at primary care facilities (such as birthing centers), 40% at secondary hospitals, and 46% tertiary hospitals. Overall 25% of all births are C-sections, and at Wellington and Auckland, our largest tertiary hospitals, over 30% of births are cesarean. For comparison, the overall C-section rate in the UK is 25% and in the US 33%; and in Nordic countries the rate is closer to 15. In the US, just 9% of births were attended by midwives, and fewer than 1% of U.S. women have their babies at birth centers. I don’t want to imply that the New Zealand system is prefect. We have issues with inequality and access to care – for example up to 11% of the population appears not to be registered with a Lead Maternity Career.

As Atul Gawande argued recently in the New Yorker, unnecessary medical care is harming patients physically and financially. The answer to rising health care costs is primary care. This seems to be just as true for maternity care as other services. Countries with stronger primary care systems provide less unnecessary interventions during low risk pregnancies and births.