I think about my role in birth a lot.
I daydream of the day when chiropractors are not only part of the regular prenatal care, but also there on the Labor & Delivery floor to assist the midwives and birth providers. I’ve gotten that call a few times from the midwives, the last-ditch effort before she transfers to the hospital for the birth that team wanted to avoid. I even went through that with the birth of our son. I can tell you it isn’t a 100% solution, but if a laboring mom is heading north of 12 hours an adjustment is always worth a try.
As chiropractors we face some pretty obvious challenges: Hospital privileges aren’t just handed out, which is a fact true for all health professionals. For instance our family practice medical doctor couldn’t attend our son’s first moments because, even as an M.D., he didn’t have privileges at our hospital. I was in talks with one administrator about partnering with their Wellness Center and was reminded during a phone call to screen my qualifications of exactly how deep the bias against alternative health care providers runs. Those that do accept that chiropractors are licensed professionals are fine as long as we stay in the Orthopedic or Physical Rehabilitation arena. My suspicion is that it’s our own fault as a profession because the low hanging fruit of the research tree, treating back pain, is where we have told them we belong.
I don’t really see the politics of medicine as an insurmountable hurdle. At the end of every conversation I’ve had with a medical provider, he or she understands what I do and recognizes I don’t have two heads and a tail; I’m here to help our patients, and I do so by providing conservative care. The biggest obstacles I see are actually within our own culture as a profession. First, we’d have to wrap our heads around either an on-call system or a position like one local hospital has with 24-7 OB hospitalists on staff in case of emergency. One of the things that’s always stood out to me about top-notch midwives is the feeling I get that they live for that middle-of-the-night phone call telling them a baby is on its way. In college I worked the swing shift when most of the world was asleep, and let me tell you it took me a lot of coffee to be as cheery as my midwife was at 3 am.
The other cultural hurdle is trying to fit chiropractic services into the existing medical model of care. As I mentioned the world recognizes chiropractic is good for back pain, and midwives have translated that into sharing our theory that it’s possibly useful for back labor as well. One of the biggest questions is how we would bill and code for those services during a delivery. The computers at Blue Cross are likely going to pick up a chiropractic adjustment code in the middle of a list of pregnancy and birth codes and reject it as a typo. This means reconciling for insurance companies that the services we’re providing aren’t just about lumbalgia relief. It would also mean a demonstration to Medicaid, who pays for half of all births nationwide, that our services make birth more cost-effective. I lobbied in Washington D.C. as a student for a demonstration project that put chiropractors in military bases, and I can testify it took a lot of people a lot of time (and Super Lotto kind of money) before the government recognized the benefit in reduced hospital stays, faster recovery, and quicker return to active duty. Eventually they did, and now there are chiropractors at 60 military bases around the US.
I can also attest first-hand that introducing a mother to chiropractic for the first time while she’s in between contractions is not the easiest consultation in the world. It’s a little like teaching a driver about how to fasten her safety harness during lap 350 of the Indy 500. As she’s driving. I think most health care providers would agree that a degree of familiarity makes our jobs easier. I felt like I was flying blind when I was called to adjust mothers I’d never laid hands on before. I have a lot of faith in my exam findings, but there’s no getting around the fact that you’re in a much more dynamic situation as a baby is attempting to move through the pelvis. If I know how a mother’s sacrum usually moves or subluxates, I can tell if what’s in front of me is normal for her or something that’s going to take an adaptation of my usual technique. I may be stating the obvious, but my experience tells me that mothers who get adjusted regularly rarely need to call the chiropractor during birth. I tracked birth stats for a year and found most of my patients have pretty “boring” labors. The average time from contractions being 3 minutes apart and regular to the moment baby is born is 14 hours in the US. For my patients who birthed vaginally, most of them did it in under 9. We’re diving deeper into that data this year and should have some interesting results to publish in 2017.
As I reflect on this, my best case scenario looks like a team of 3-5 salaried chiropractors staffed by the midwives group. The patients would be screened at 20, 28 and 36 weeks and recommended an appropriate course of care. The chiropractors would be salaried and their services would be bundled with the global fee for prenatal midwifery care. At least one chiropractor would be available around the clock to assist in assessing laboring moms at admission and re-assessment with correction as necessary at the request of the birth team. The overhead is incredibly light; less than $8000 would purchase all the equipment the team would ever potentially need for adjusting the pregnant pelvis including a table in the office and a mobile one for the Labor & Delivery floor.
However, I don’t think a midwifery group alone could afford 3-5 chiropractors. Either the physicians group I’m picturing in my head would have to also utilize the chiropractic services, or the hospital would need to be their employer. If chiropractic made births more cost effective by lowering levels of intervention, the necessary question would be why a hospital would pay for services that make them less money. Unless I was working for a very altruistic system that believed in promoting natural health simply because it was the right thing to do, the short answer is it wouldn’t without incentives. Again, this is where third parties like Medicaid come in. Payers want cost-effective services, and when you’re paying for half of all births, it gives you a ton of leverage to dictate the terms of conservative care. It’s pretty straight-forward; the people who hold the purse strings essentially write the policies. While I don’t know that it would become a mandate in my lifetime, I do remember 14 years ago that the number of chiropractors on military bases could be counted on one hand. Change in the large machine happens at glacial speeds, but it does happen.
All of this remains a daydream without research. It starts with committed doctors who are willing to do a little more than run the day to day operations of their offices and start publishing the cases they’re seeing. For example in my private practice, regardless of the hours of operation, I’ve always put in a 60 hour work-week time investment. There are no “off-days,” when you’re attempting a paradigm shift. I saw the value in adding a clinical research assistant to my staff because someday I want a chiropractic student to be able to hand a Congressional staffer a stack of papers like I did that explains the same thing for pregnancy that we demonstrated for our men and women in uniform: Chiropractic helps in ways you didn’t realize, and not investing in us costs you money. My passion hasn’t been easy on my family, but I deeply believe I’m doing work that I’ve been called to do. I can’t really explain why, but I feel I have a responsibility to the profession and to expecting mothers to advance the work of perinatal chiropractic.
That’s why I love this case report. It was written by 3 people I know really well. I’ve come to love Dr. Justin Ohm as my chiropractic twin, his mother Dr. Jeanne as the matriarch of the ICPA, and Dr. Alcantara has not only been my co-author, he’s become one of my best friends. I love these people because the passion for what we do slobbers off their chins as much as it does mine. There’s a growing corps of us that are plugging away at the evidence gap one report at a time, and each paper not only serves as a brick in that research pyramid, but also helps nudge moms who aren’t sure if chiropractic is right for them into giving it a chance. We’re building a cycle of publishing and public acceptance that, and I hope this does happen in my lifetime, will result in every mother who decides on the midwifery model also knows she’s adding a prenatal chiropractor to her team.
“Collaboration with midwives and chiropractors may help to resolve dystocia.” Read how http://icpa4kids.com/fwf/2016%20Newsletters/Research_July2016.pdf
