What SUVs Can Teach Us About Maternity Care

December 6th, 2009 by avatar

Twice last week, analogies between sport utility vehicles (SUVs) and the organization of our maternity care system came up in blog comment discussions. In a spirited discussion between Katharine Hikel and AcademicObgyn.com‘s Nicholas Fogelson on Hikel’s post, Disputed Territory, she proposed, “maybe it’s time to change from the SUV model to the compact hybrid…The ACOG hospital model is neither sustainable nor affordable.” In a thoughtful post about military terminology and philosophy in healthcare at e-Patients.net, again conversation turned to the American enhusiasm for SUVs.

Henci Goer and I decided it would be fun to share a sneak peak excerpt of our book, Obstetric Myths versus Research Realities, 2nd edition, due out late next year. With apologies to those who drive SUVs, here it is…

What SUVs Can Teach Us about Maternity Care
Excerpt from Goer, H. & Romano, A. (In Press)
Obstetric Myths versus Research Realities, 2nd Edition, The University of Michigan Press: Ann Arbor, MI.

A recent advertising campaign for a large sport utility vehicle (SUV) offers an excellent analogy to conventional thinking in maternity care. Parallel to the “just in case” approach of obstetric management, the ads acknowledge that the average SUV driver will hardly ever need the heft and power of an SUV, but the “one percent” chance of being caught in a blizzard or hurricane means the driver would be wise to own a vehicle that can safely navigate treacherous conditions. The SUV, the ads declare, is “built for the one percent.” Let us see how the flaws in this argument translate to maternity care.

SUV creative commons1

  • The technology that makes an SUV superior in severe adverse driving conditions provides no benefit to the driver 99% of the time because severe adverse driving conditions are rare. Likewise, the technology that can improve outcomes in very problematic pregnancies provides no benefit to most women and babies most of the time because these conditions are rare.
  • Most SUV drivers live in temperate climates, where the likelihood of a blizzard or similar natural disaster on any given day is extremely low. Likewise, most pregnant women are healthy and at low risk of experiencing a “natural disaster” during childbirth.
  • The driving conditions in which an SUV offers an advantage are usually predictable. Blizzards and hurricanes, for example, rarely take a driver completely by surprise. Likewise, we can often predict which women will develop complications in pregnancy or birth. Most pregnancy and labor complications develop slowly, giving plenty of time to avert them or access the resources needed to safely manage them.
  • Individuals and society as a whole expend resources to build, fuel, and maintain SUVs and to accommodate them on our roadways despite the fact that most people could drive smaller cars most of the time and be equally well off—or better off. Likewise, technology-intensive obstetric management is extremely costly and requires specialized staff resources and physical infrastructure to support it, despite the fact that a lower-technology approach with access to technology when it is indicated provides equivalent or better outcomes.
  • Although the SUV’s bigger size and greater weight offer some protection when collisions occur, these same characteristics make them more prone to accidents. The weight of the vehicle makes it more difficult to brake to avoid collisions and the higher center of gravity is responsible for more rollovers. The net effect is that SUVs may actually be more likely than smaller cars to be involved in serious or fatal accidents to drivers or passengers. Likewise, obstetric interventions can be beneficial in some circumstances, but their use frequently results in iatrogenic harm. The net effect is that women and infants often fare worse than if they had not been exposed to the intervention in the first place.
  • Some people choose an SUV because they genuinely need one for the road conditions under which they do most of their driving. In these cases, an SUV makes sense. Likewise, women who have medical problems or are likely to develop pregnancy or labor complications will benefit from intensified use of obstetric technology. These women are likely to seek out specialist care.
  • Although we can measure the degree to which weather or traffic conditions are poor and accidents more likely, this information cannot tell us which cars are destined to get into accidents or whether any individual accident will be minor or major. Similarly, screening tests (e.g., fetal surveillance, electronic fetal monitoring) and prenatal risk or candidacy for VBAC scoring systems have poor predictive value and lead obstetricians to over treat. They also fail to distinguish problems where intervention can help from problems where it cannot.
  • Most accidents are fender-benders that cause no more than minor harm no matter what kind of vehicle is involved. Likewise, most complications in pregnancy and birth are minor and will not result in any serious or long-term harm to mother or baby no matter what kind of care they receive.
  • Some accidents will cause major injury or death no matter what kind of vehicle is being driven. Likewise, some babies and even some mothers will suffer severe morbidity or die no matter what kind of care they receive. Even in the best-equipped hospitals with superbly qualified staff, in some cases, nothing can be done to prevent the worst from happening.

Midwives Deliver bumper sticker2

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  1. | #1

    Genius. GENIUS!

    From now on, I will think of this with every Escalade and Hummer I see. And those Hummer stretch limos? Electively scheduled cesarean.

  2. | #2

    Electively scheduled cesareans are because patients want them. It isn’t an objective decision. Some people want to schedule their birth.

    People drive SUVs for the emotional “like” of the thing, not for objective reasons. Of course they’re inefficient and foolish in 99% of the situations they are driven. In some parts of the country the cool car to have is a full size truck, even though most owners never put anything in the back (which is why they have to get the quad cab to fit the family!).

  3. | #3

    I drive a Jetta, but I got the sporty GLI version because I like to vroom-vroom. More practical? More than an SUV, but less than the cheaper version. But the benefits are not just objective, are they?

  4. | #4

    What and interesting and very brave analogy. Some people will be offended but it makes perfect sense and it absolutely true. I can’t wait for the the new edition of the book to come out!

  5. avatar
    Carolina Mama
    | #5

    Actually, some people drive an SUV simply because they don’t make a mini-van that seats a family of 9 comfortably and that can handle to weight of their gear.:-)

  6. avatar
    alexa gilbert
    | #6

    This is a very welcome article. I agree with every last word.

    Also, re: “my apologies to those who drive an SUV”…….never apologize to someone with an SUV. Sorry, but they have a choice to drive something more efficient during a key time of unprecedented climate change– they should be apologizing.

  7. | #7

    I’m pleased and not entirely surprised to see some discussion on this post already.

    Yes, there are a lot of reasons we each drive what we drive (or avoid driving altogether). Cost, safety, efficiency, self expression, family needs, lifestyle, etc. And while I have personal opinions about what constitutes an appropriate vehicle, I see Americans’ enthusiasm for SUVs to be more than just a collection of people’s expressed desires. And those desires are more than just a calculation of risks and costs. To extend the metaphor, that’s why talking only about the (far less than) “1% chance” of a lifethreatening outcome in birth is not going to convince every last woman that she needs to prepare for worst case scenario as if it is a certainty. Women incorporate into to birth choices both emotional and rational considerations, as well as personal and political values.

    I think car companies have been successful in promoting SUVs as offering superior safety. Does that explain why every SUV driver drives an SUV? No, but the advertising messages have certainly pervaded our culture to the extent that some people think that if you drive your family around in a compact car that you’re unnecessarily endangering them. On top of that, energy policies, fuel costs, road conditions, how our communities are planned, how we live and work, etc. etc. etc. all weigh on people’s decisions about what vehicle(s) to own as well, and they all tend to favor people buying and driving more car than they need.

  8. | #8

    I just LOVE it!!! Thanks for the sneak peak!

  9. avatar
    Ahmie Yeung
    | #9

    @Amy Romano
    It’s not just the personal decisions, some people also take into account how many other people are already driving SUVs. I lived in an area where SUVs and minivans outnumbered other vehicles about 2 to 1 for a while and heard this kind of conversation going on. The marketed perceptions of SUVs seem to inspire a certain cocky attitude (as does the availability of technology in hospital birth situations) and, in my experience, contributes to the unpredictable nature of others while driving SUVs (it’s a big vehicle! It has 4 wheel drive! That “bridge freezes before road” sign doesn’t mean me!). The likelihood of injury to a driver/passenger in a subcompact car when hit by an out-of-control SUV is significantly higher than that of someone in another SUV (for one thing, the height of the SUV’s bumper relative to the subcompact’s frame). Some people take this communal issue into account when chosing a vehicle.

    To me, this is an analogy to women expecting a twin, breech, etc birth in an area without professionals experienced in birthing those less-common configurations vaginally. If none of the available care providers have ever participated in a breech or multiple birth other than via c-section, then you and your child(ren) are safer going with the c-section instead of being the provider’s first experiment. Those situations and more can be safely handled vaginally, even at home, with experienced care providers, but if your care provider has never driven a subcompact and has only ever driven SUVs with multiple/breech births…. that’s scary!

  10. avatar
    Monica Waggoner
    | #10

    [bullet point:] The costs to society of driving an SUV are not fully captured by the increased purchase, registration, or fuel/maintenance costs to the vehicle owner. Externalized costs spread the burden of that “choice” across society. Similarly, the external costs of losing a birth climate where a safe, intervention-free birth is available to all women are not captured by the invoices negotiated between insurers and hospitals for a given birth.

    Furthermore, the pricing of birth has shaped much of our health industry… prenatal care and childbirth are ALWAYS billable to someone, so that’s cheap business that can turn a profit for low-cost clinics, public hospitals, and the like. Hospitals now compete for maternity patients, sometimes at the expense of other programs… much as car companies may invest in R&D for the latest and greatest SUV, rather than innovating sedan design to improve gas mileage and safety beyond required regulations.

  11. | #11

    Honestly if you wanted a very efficient delivery system, a diesel would be better than a compact hybrid. America’s all excited about hybrids, but diesels are just as efficient and drive better. A diesel hybrid would be the best!

  12. | #12

    What’s the diesel hybrid, the freestanding birth center with operative and anesthesia facilities?

  13. avatar
    Jennifer stevens
    | #13

    Absolutly! I immediately thought of a freestanding Birthcenter as the hybrid! Brillant

  14. | #14

    Sorry I am late to the thread. I want to be in the diesel hybrid birth center, too!

  15. avatar
    | #15

    Hahaha LOVE it!!

    I guess I missed you posting this on FB, Amy? I need to check in here or subscribe!

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