April 18, 2009

The Bridgeport Paradox: Black and White in the Delivery Room

Connecticut is one of the richest states in the United States. Most of its many wealthy people live on the 'Gold Coast' which is within commuting distance to New York City and is along the shore of Long Island Sound. The richest county in Connecticut is Fairfield county, where low-density communities are filled with some of the most expensive private homes in America.

There are no major hospitals in these affluent towns, owing to their low population density. So when the rich and famous need a hospital, they go to the nearest major medical center, Bridgeport Hospital.

Bridgeport is an island of poverty in this sea of wealth. A booming 19th-century industrial town, it gradually ran out of most manufacturing jobs decades ago. It has double the state's average rate of people living in poverty, and triple the rate of the poorest poor—people living at less than 50% of the poverty rate.

When I did my required training rotation through Obstetrics, I was assigned to Bridgeport Hospital. It's a big urban medical center, with a busy Labor & Delivery ward. Almost all of the Obstetricians in the area had luxurious private offices located in the adjoining wealthy communities, where they served an exclusive clientèle, mostly white. For deliveries, however, even the fancy doctors used the great facilities at Bridgeport (in private rooms). Some of these doctors in private practice, along with the doctors on staff at the hospital, also worked with the patients from Bridgeport, mostly women of color. Most of these patients didn't have private insurance, and sometimes didn't have insurance at all. These patients often had less prenatal care, and less access to medical care in general for any of their other medical needs. Many had complex social issues associated with poverty which complicated their care.

In this context, I expected that the wealthy, private-paying patients with their private physicians would somehow get better treatment and have an easier time. For many types of medical problems, this seems generally to be the case, and I expected it at Bridgeport Hospital, where the stark contrasts in patient resources are dramatic.

The experience of my first day has remained deeply etched in my memory. I was told to wait at the nurse's station of the obstetrics ward. The screaming started within minutes of my arrival. It was the most disturbing sound I had ever heard. Clearly screaming in severe pain, the halls were filled with this sound which came from behind a closed door. I was new there, but I asked the nurse sitting next to me, who was browsing through a catalog for scrubs with cartoon characters, if we should go in there and help. She was very kind and explained that the obstetrician was already in the room and the woman had said that she didn't want any interference or medication. Within a couple of hours of this, a new patient was wheeled in to another private delivery room. With her was her husband, her doctor, and her personal secretary. After getting settled, the personal secretary left the room and sat in the waiting area. A second source of intense and disturbing screaming started coming from this room, too. Now there were two.

Before lunch, an ambulance brought in one of the local women, and the nurse sitting next to me dropped her catalog (by now she had moved on to a shoe catalog), and prodded me to come along. I didn't do anything at my first delivery, but I watched a very skilled doctor give this woman an epidural anesthetic. A couple of hours went by before she had her baby, which is about the most fabulous thing a person could witness. She pushed and was awake and happy when the delivery nurse put her new baby into her arms.

I don't know what happened in those private rooms, as I was never invited in. But this experience was repeated nearly every day I was there. I asked one of the obstetricians about it. She told me that many of her private patients refused all medications and wanted what she called the 'full experience' of childbirth and motherhood. She said this wasn't often the case with the inner-city mothers she treated in the hospital. She never really thought about it, and tried to give her patients what they requested.

So much suffering, both medical and otherwise, falls heaviest on the poor. What I witnessed was counter-intuitive: the rich were enduring unspeakable pain, and the poor were not. I'm not an obstetrician, but I do look upon my job as trying to ease suffering if I can. Were the poor women getting better advice than money could buy? Maybe they just had more common sense.

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