Have Uterus Will Travel

New Mexico - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

“Teenage pregnancies continue to be a problem throughout the country. It perpetuates the cycle of poverty and makes it difficult to achieve educational and professional goals.” -- Essay subject given to medical scholarship applicants from a local high school.

Each year our medical group provides a four year academic scholarship to aspiring physicians, and each year the applicants are required to write an essay proposing a solution to a complex medical or social problem. This year nearly all of the finalists felt sex education and parental influence were most crucial in solving the teenage mother problem -- reasonable answers, but birth control is widely available and many teen mothers do not have an influential parent to guide them through these difficult years.

Last month while working on the hospital’s obstetric floor, I cared for a 20 year old single mother who was having her fourth cesarean section. She was 4 foot ten inches tall and weighed 210 pounds, dropped our of high school at age sixteen, and chose to raise her family without the fathers of her children. During the operation with her mother at the bedside, her obstetrician announced she had delivered a baby girl, and he would see her again next year when she tried for another boy.

Put yourself into the shoes of a poorly educated teen mother without a positive role model who is destined to work in low paying service industry jobs for a lifetime. There is no prospect of travel, owning a home, or living a life unlike her mother. Given the circumstances, having children is not an unattractive alternative if the government provides cash, housing, medical and child care, food stamps, and transportation, while not having to deal with employers who insist on punctuality and demand a certain level of performance.

Obstetrics is one of the few specialties where a welfare Medical provider physician can earn as much for a procedure as a private physician caring for a commercially insured patient. The financial enticement insures low income women will receive obstetric care, but it also encourages providers to manage practices based on high patient volume. Whereas as private physician will typically deliver twelve to fifteen babies per month and know their patients well, a MediCal doctor will deliver sixty babies in the same time frame but may not have seen the patient until delivery time.

Another quirk of the welfare obstetric business is a program which allows the obstetrician to bill the State of California for nutritional counseling during pregnancy. The service is offered through the physician’s office and is intended to teach the patients to eat properly and maintain weight control during pregnancy. Who could quarrel with a goal which is good for mother and good for baby? Anyone who works in labor and delivery would agree that there are more MediCal patients who weigh over 250 pounds than weigh less than 150. It is not uncommon to care for patients weighing 350 pounds who suffer from diabetes and high blood pressure, but have had tax payer paid nutritional counseling during pregnancy.

What about the obstetrician's flippant comment that he would see his patient again next year for another cesarean delivery? There is a powerful financial incentive to encourage parity. Obstetricians exercise profound influence over their patients and perhaps more so in the case of patients without husbands or a supportive, discerning family. Large, production based practices favor less personal engagement with patients who tend to be unsophisticated and susceptible to manipulation.

Before dismissing these thoughts as a misogynous tirade, the real culprit is the social welfare system which insures these young women and many of their children will fail and fall deeper into dependency. There are substantial financial rewards for welfare mothers and the physicians who care for them. Programs to help welfare mothers break the cycle of poverty were discussed in a previous article. (Makin Babies) In the physician case what would happen if reimbursement was based on successful family planning rather than the number of babies delivered? For example, after the first delivery the obstetrician’s fee would be drastically cut for subsequent deliveries within the next five years, but reimbursement for family planning would increase to make this part of the practice economically viable. Reimbursement for “nutritional counseling” during pregnancy would only occur if the patient met certain weight restrictions during pregnancy. Document the patient’s weight in a hospital at the beginning of pregnancy and weigh her at delivery time. If the weight gain is satisfactory as stipulated by the American Board of Obstetricians, then reimbursement occurs, otherwise nothing for sham programs which do not ensure results.

The scholarship applicants felt education is key to solving the teenage pregnancy problem. However, their concept of education is sex education, and none of them addressed the importance of educated mothers. Women with a marginal academic backgrounds often raise their children in areas where the quality of public instruction is abysmal. The chance their children will succeed unless they are fortunate enough to attend a charter school is vanishingly small. (Waiting for Superman) Educated women tend to limit the size of their families, and their children are more apt to be educated and independently employed, while less likely to use drugs and have criminal records. This goal is more difficult to achieve if welfare mothers and the physicians caring for them are rewarded for behavior that digs a hole so deep that only an exceptional woman can extricate herself.