infant mortality
Mamas on Bedrest: $5 Billion on Moms and Babies!
January 9th, 2013$5 Billion dollars. Yes that’s Billion with a “B”. That is the amount of money that the United States could potentially save annually on medical costs related to maternity care according to The Cost of Having a Baby in the United States, new study published by Childbirth Connection, Catalyst Payment Reform and Center for Healthcare Quality and Payment Reform. The study was prepared by Truven Health Analytics and released January 7, 2013.
It’s no secret that the US healthcare system is in deep trouble and if it continues in its current iteration, it could very well bankrupt the entire country in the not too distant future. With the passage of the Affordable Care Act, the federal government made an attempt at reducing costs while at the same time making health insurance more available to more Americans. But it is safe to say that no one thinks that the ACA in its current form will be the answer to all that ails our flailing healthcare system. In an attempt to see where there are potential cost savings, several different agencies (public, private and non-profit) have undertaken studies to evaluate the type and quality of care provided in the United States in different health care arenas. In this study, maternity costs were analyzed in an effort to determine where there are not only potential cost savings in maternity care, but also potential reductions in risks to maternal and fetal/infant health.
The study is presented in an 86 page document. One of the most remarkable findings is the fact that there are roughly 4 million babies born in the US annually and now a full one third or 33% are born via Cesarean section. This represents a 50% increase in cesarean deliveries in the last decade, and many cesareans performed are not medically necessary. Unnecessary cesarean sections have been shown to increase health complications for both mother and baby. But what was found in this study is that cesarean sections dramatically increase the cost of maternity care. According to the study,
“For the commercially insured, the average cost of a birth by c-section in 2010 was $27,866, compared to $18,329 for a vaginal birth. Medicaid programs paid nearly $4,000 more for c-sections than vaginal births. If the rate of c-sections were reduced from 33% to 15% (the World Health Organization recommends a c-section rate of 15% or less), national spending on maternity care would decline by more than $5 billion.”
The study also found that the cost of care for mamas increased 40% from 2004-2010 and this did not include costs of infant care, and also noted wide variation in costs from state to state and within states. According to Harold Miller, Executive Director of the Center for Healthcare Quality and Payment Reform (CHQPR),
“Maternal and newborn care together represent the largest single category of hospital expenditures for most commercial health plans and state Medicaid programs, so reducing maternity care costs provides a major opportunity to reduce insurance premiums for employers and to make Medicaid coverage more affordable for taxpayers.”
Another startling finding (in my opinion) is the fact that the uninsured may be charged. According to the study,
“Uninsured parents could be charged over $50,000 for a baby born by c-section and over $30,000 for a baby born by vaginal birth. Average provider charges for a c-section in 2010 were $51,125, but commercial insurance plans only paid $27,866, 55% of what an uninsured patient could be asked to pay.”
Other startling findings:
- Vaginal births cost $18,329; c-sections cost $27,866 (for the commercially insured, 2010) and these costs are substantially more for the uninsured.
- Medicaid, which pays for over 40% of all births, paid nearly $4,000 more for c-sections than vaginal births.
- If the current national rate of c-section were reduced from 33% to 15% (the World Health Organization recommends a rate of 15% or less), we could save $5 billion!
- The cost of maternal care (not including newborn care) jumped an incredible 40% between 2004 and 2010 for the commercially insured.
- The total commercial payments for care of newborns were $5,809 for babies delivered vaginally and $11,193 for cesarean births. Total Medicaid payments for newborn care were $3,014 for vaginal births and $5,607 for cesarean births. Reducing the rate of prematurity among infants could significantly reduce these costs.
- The largest share of all combined maternal-newborn costs goes to pay for hospital or other facility costs regardless of the type of birth. 59% of total maternal and newborn care costs for vaginal births are used to pay facility fees, and 66% of costs for c-sections are for facility fees. Similarly, the hospitalization phase of childbirth consumed from 70% to 86% of all maternal and newborn care costs, depending on payment source and type of birth.
- There is significant variation in cost within and across states.
If the United States is serious about health care reform, obviously maternity care reform has to be at the top of its list! If pulling the US cesarean section rate in line with World Health Organization recommendations would truly result in a savings of $5Billion dollars, we should be seriously looking at ways to reduce the number of cesarean sections performed. Likewise, since hospital fees represent more than 70% of maternity care costs, it behooves us as a nation to consider increasing the availability and accessibility of birthing centers and, for those low risk women, home births. Many other countries utilize nurses and other health care providers to provided additional care to mothers and babies in their homes before and after birth (The models upon which Mamas on Bedrest & Beyond is designed!) which has been shown to greatly reduce the numbers of hospital admissions and care costs. The US has the means, the skills and expertise and the workforce (talking about A LOT of potential jobs here!) to provide such care and hence, further reduce the cost of maternity care and the burden on the US health care budget. If as a nation the US fails to implement of these recommendations, we will continue to face spiraling out of control maternity care costs, and, more tragically, more perinatal complications, catastrophes and deaths of mamas and babies.
Childbirth Connection is a national not-for-profit organization founded in 1918 as the Maternity Center Association. Its mission is to improve the quality and value of maternity care through consumer engagement and health system transformation.
Catalyst for Payment Reform is an independent, non-profit organization working on behalf of large employers and other healthcare purchasers to catalyze improvements in the way healthcare services are paid for and to promote better and higher value care in the United States.
The Center for Healthcare Quality and Payment Reform is a national policy center that encourages comprehensive, outcome-driven, regionally-based approaches to achieving higher-value healthcare.
Mamas on Bedrest: Implications for African Americans from Familism Study
January 7th, 2013I’ve been mulling over the study, “Maternal familism predicts birthweight and asthma symptoms three years later” by Dr. Cleopatra Abdou and her colleagues. This study, summarized in our last blog post, states that for mamas to be, familism (assessed as maternal endorsement of traditional {cultural?} views on familial obligation) is a stronger predictor of health over and above mamas’ relationships to ethnicity, nativity, and lifespan familial socioeconomic position (FSEP). In plain terms, the stronger mamas’ beliefs in family and familial roles and obligations, the less likely they are to have low birth weight babies and children who develop asthma within the first 3 years of life.
Most people correctly assume that in well to do families, every possible provision is made to ensure that the anticipated infant has every possible advantage to have a strong start in life. It is also well known that children born to families of lower socioeconomic status and with far fewer resources, while no less loved and anticipated, are often at risk of being born low birth weight and subsequently developing a variety of illnesses as a result. But there is a paradox within all of this, first referred to as the Latino Paradox by Markides & Coreil in their 1986 publication, The health of Hispanics in the Southwestern United States, An Epidemiological Paradox. The consensus regarding the paradox is this,
It seems that among certain segments of ethnic minority populations in America, including those who are presumed to be less acculturated to mainstream America and/or to have retained more traditional (cultural) values, particularly surrounding family, unassimilated minorities are among the healthiest Americans, particularly where pregnancy and birth outcomes are concerned.
Since the phenomenon is increasingly observed in other minority groups, including U.S. and foreign born Blacks and Whites, the paradox is becoming more broadly known as the Epidemiological Paradox.
I observed this “paradox” during my clinical practice years, most notably in Hispanic and Asian families. In “traditional” families, when a mama was pregnant there was often an entourage that accompanied her to prenatal visits and although she may have been recommended certain medically accepted treatments, it was abundantly clear that mama was under the watchful eye and in the hands of of her mother, grandmother, aunts, sisters and cousins and whatever they deemed best for mama and her baby would be done (as had been done for generations of babies within that culture) regardless of what any “medical professional” had to say.
What was most striking to me is that Abdou’s most recent publication makes a clear argument that the legacy of slavery (if one can call such an atrocious miscarriage of humanity a legacy) has had profound detrimental effects on African Americans not only from a cultural and economic standpoint, but also from a health standpoint. For almost every chronic disease (i.e. Heart Disease, Diabetes, Asthma, and Most Cancers just to name a few) African Americans are at greater risk for contracting the diseases, fare far worse, suffer more debilitating complications and are more likely to die from the complications of the diseases than any other ethnic group. As a physician assistant student, I learned about the various body systems and how they work to regulate metabolism and enable the body to function. As I looked at African Americans, I couldn’t understand why diseases hit us with what seems like catastrophic effects. The Epidemiologic Paradox puts it all in perspective and gives a partial explanation.
African Americans are the only ethnic group that came to America against their will and were unable to maintain any of their cultural traditions. Families and tribes were separated, languages and dialects were forgotten, lineages were disrupted, tribal/cultural rights and customs were lost. Africans brought to America as slaves had a physiologic make up adapted for a very arid and nomadic lifestyle. In America the climate and food and environment were markedly different. Slaves were purposely separated from their families, communities and tribes, a move made to prohibit congregation and revolution. They were prohibited from exhibiting any of their nativity; dances, languages, oral traditions, dress, even names. They were not free to move about or to even eat foods to which they were accustomed or for which they were physiologically adapted. In so doing, the American Slave Trade effectively obliterated families, cultures, tribes, traditions-and the general health of African Americans.
Fast forward to today. African American women and infants have the highest rates of perinatal and infant mortality among all ethnic groups, and in light of Dr. Abdou and her colleagues’ research this should come as no surprise. What cultural heritage do African American women possess and pass on to future generations? African American women as slaves were at the whim of slave owners. African rights of passage from childhood girlish years into womanhood were replaced by random seizure and rape. The children that they bore, whether those of slave owners or of other slaves, were often taken from them either as infants or as children, and ritual pregnancy, birth and infant blessing ceremonies were lost. Traditions and rituals that should have been passed down from mother to daughter were lost and have been replaced with advice on how not to draw attention to yourself as a means to stay safe and possibly avoid sexual attention. Today some might argue that it has been replaced with do whatever it takes to get and keep a man-any man-even if he doesn’t respect you or treat you well in light of the deplorable state or African American relationships and families. But that is a discussion for another time. By and large it is safe to say that the family structure in African American culture is severely fractured, relationships between African American men and women is strained, African American children are at risk for sickness, disease, violence and death and if we accept and understand the Epidemiological Paradox as a veritable and verifiable factor in the health of Americans of different ethnic backgrounds and cultures, then we have to acknowledge that this paradox is no more clearly evident than in African Americans.
African Americans have little to no native culture upon which to draw. Most of us don’t have century old traditions or regal family ties. Many African American mamas have little or no support and move through the prenatal period alone, while at the same time trying to navigate where they are going to live, how they are going to eat and how they are going to pay their bills. If they have other children from other relationships they also face social disdain and at times overt disgust for their station in life. And even when everything is “in order” there is the pervasive perception that African American mamas and their babies are less likely to be of means, education or ability. I say this from experience as when I had my son, I was married and insured and yet the day after my son was born, a social worker came into my hospital room and proceeded to present me with “information I would need” to apply for WIC and medicare for my son. She obviously never looked at my chart for she would have seen that we had private insurance and that we were in no way eligible for-or in need of-WIC.
The current American culture is a capitalistic, solitary, “dog eat dog” type of culture. Americans pride themselves on “pulling themselves up by their own bootstraps”, ”being self made individuals” and “I did it my way.” The work of Dr. Abdou and her colleagues, the Epidemiologic Paradox in other Americans who have retained their native cultures and the life and legacy of African American people shows us that this American lifestyle is unhealthy to say the least and for African Americans (as well as for people of other cultures who become more accustomed, more Americanized), it’s deadly plain and simple.
As Dr. Abdou rightly states, cultural familism is a readily available resource for many women. The next thing we health care practitioners, advocates and public health scientists must do is consider how we’ll take this information and the resources available to us to help craft a cultural resource for African Americans in the hope of not only lowering maternal and infant morbidity and mortality rates, but improving the overall health and well being of African Americans as a whole.
References
Cleopatra M. Abdou, Tyan Parker Dominguez, Hector F. Myers. Maternal familism predicts birthweight and asthma symptoms three years later. Social Science & Medicine, 2012; DOI: 10.1016/j.socscimed.2012.07.041
Markides, K. S., & Coreil, J. (1986). The health of Hispanics in the Southwestern United States An Epidemiological Paradox. Public Health Reports, 101, 253e265.
Mamas on Bedrest: A Strong Family Cultural Identification Predicts Low Birthweight and Childhood Asthma
January 3rd, 2013First and foremost, Happy New Year Mamas!
It is my pleasure to step into 2013 by sharing with you all some fascinating-albeit not that surprising-data from one of my favorite researchers, Cleopatra Abdou, PhD. Dr. Abdou is an assistant professor at the USC Davis School of Gerontology in Southern California. She studies the associations between culture and health.
In this current study, Dr. Abdou and her colleagues sought to discover if a strong cultural belief in family had any effect on the birth weight and subsequent health (in this case asthma expression) of infants born to low income mothers. Abdou and her colleagues studied 4633 African American, Latina American and White American women and their babies through their pregnancies and for 3 years post partum. The researchers looked at the infants’ initial birth weights and subsequent asthma development/expression. Abdou and her colleagues found that very low birth weight infants were at increased risk of developing asthma in the first 3 years of life. This in and of itself was not surprising. It is a well established fact that babies born early have an increased risk of developing chronic health issues throughout their lives. Additionally, infants born to mothers of very low socioeconomic status are at increase risk of being born at a low birth weight. However, what was surprising in this study was that infants born to mothers with a strong cultural belief in family-regardless of their own family ties or current level of familial support-tended to be of higher birth weight, fared better overall and as a result were less likely to develop asthma later on.
These results were interesting to say the least. Abdou and her colleagues were able to show that an “intangible” cultural belief is strong enough to have a physiologic impact on maternal and infant health. In mothers who held strong beliefs in “traditional” family roles and responsibility, i.e. you do whatever it takes to maintain the health and well being of the family, these women, regardless of their socioeconomic status or current familial support had better birth outcome, i.e. larger birth weight babies.
Abdou’s findings added clarity to the so-called “Hispanic Paradox” or “epidemiologic paradox.” First documented in 1986 by Markides and Coreil, these researchers found that immigrant populations in the United States tend to be relatively healthy compared to their peers, despite being poorer. This recent data supports this paradox and also helps to explain why the paradox diminishes over time as immigrants assimilate into American Culture. To sum up, when immigrants or Americans of different ethnicities, African Americans and Latina Americans, maintain strong cultural ties to their “mother lands” they tend to have better birth outcomes and are healthier-even if they are poorer. This effect wanes as the families become more “Americanized”.
As Abdou notes in her publication, this cultural familism could play a significant role in the health and well being of low income families. Familism is readily available to women in the form of mothers, grandmothers, aunties and other older female relatives. I a woman is able to draw on her heritage, her positive cultural upbringing and beliefs around family, she may be able to give herself and her family a distinct health edge.
Reference
Cleopatra M. Abdou, Tyan Parker Dominguez, Hector F. Myers. Maternal familism predicts birthweight and asthma symptoms three years later. Social Science & Medicine, 2012; DOI: 10.1016/j.socscimed.2012.07.041
