neonatal mortality
Mamas on Bedrest: Mamas With No Money and No Insurance
January 23rd, 2013
I live in Texas, not by choice but by circumstance.
As such I watch, with utter disgust, the Texas legislature cut and defund programs that have significant impact on women and children. The mantra here in “The Great State of Texas” is that “We pull ourselves up by our own boot straps and we take care of our own.” The sad truth is that those who can afford boots may in fact be able to pull themselves up by the straps, but for many hardworking Texans, it’s a struggle to make it from day to day and Texas is not doing a very good job of “taking care of its own.”
What many hardworking Texans don’t know is that with the passage of the Affordable Care Act, (ACA) there are federal funds available for each state to utilize so that they can increase the number of citizens who have access to health care. The funds typically go to support Medicare and Medicaid programs. Texas Governor Rick Perry is on the record as vehemently opposing the ACA and has vowed not to accept any federal funds. By rejecting these funds, Governor Perry ensures that some 6.1 million Texans remain uninsured.
Now I am in favor of everyone having his or her own opinion about government and the law. However, I think that when you are in a position of authority and you are making decisions for the general population, you need to step back from your personal views and look at what will be in the best interest of the greater population. Governor Perry and many Republicans vehemently oppose the ACA. However, it is the law and as such, there are provisions within the law that actually benefit a lot of people. In particular, the fact that the federal government has set aside funds so that the individual states can access these funds and use them to insure and care for their constituents is a good thing. Stubbornly denying the funds because you, a wealthy and well insured government official, have a philosophical difference with the government (okay, let’s be frank, the President!), and will as a result deny help to millions of your constituents is deplorable.
So why am I bringing this up on Mamas on Bedrest & Beyond? Because here in Texas, we have a large number of mamas who are either under-insured (their policies don’t cover maternity care) or they are uninsured. Texas also has some of the highest infant and maternal mortality rates in the United States and these rates are even higher for mamas of color. Women should not have to decide between keeping a roof over their heads and whether or not to start a family. The two should not be mutually exclusive. Mamas (and any children that they may have) need health care coverage and Texas Medicaid is struggling. Federal funds could go far in assuring that many hardworking Texans have access to safe, quality health care. A common misconception is that people on Medicaid are slackers, sitting about waiting for a handout. While this may in fact be true of some of the people receiving Medicaid benefits, there are just as many hard working people working low paying jobs that don’t provide (health care) benefits. These folks deserve to have access to quality health care.
But there are some really great folks out there working to ensure that all Texans, but mamas and babies in particular, have access to quality health care. In a bold move, Mamas of Color Rising has started MamaSana, an all volunteer free pregnancy clinic here in Austin. Mamas of Color Rising has also been instrumental in challenging the Texas Medicaid system to do more to support low income/mamas of color; petitioning the Texas Medicaid system to change it’s rules so that Licensed Professional Midwives will be able to attend births for low income/mamas of color and be reimbursed by TX Medicare, they have advocated for mother friendly birth practices for low income women and they have created a movement to ensure that all women have access to the best possible perinatal care, provided by caring health care providers and are aggressively pressing the Texas legislature to support their efforts. You can learn more about Mamas of Color Rising’s work here.
Here in Texas we are going to have to be vigilant and vocal when it comes to health care. We residents, constituents, have to continually press the legislature and the Governor to do the work of the people-and to work for the people. No matter what he may think of the Affordable Care Act or President Obama, Texans need a strong Medicaid program- many mamas and babies depend on it. And it is an ill conceived plan to refuse federal funds based a stubborn, prideful, philosophical difference-which in the end will have no effect on you or the quality of your life, but will greatly impact the lives of millions of others.
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.
