Cesarean Sections

Mamas on Bedrest: The End of Elective Inductions??

May 24th, 2013

Many American hospitals and Obstetricians have put a “hard stop” on elective labor inductions. As a result many hospitals and physicians are seeing a significant drop in still births, NICU admissions, cesarean sections and post partum hemorrhage. Data presenting the effects of such hospital practice policies was presented at the American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting.

The United States has long been noted to have adverse birth outcomes that, in some instances, rival those of developing nations with far fewer resources. With the world’s eye upon us, many hospitals adopted a no elective labor before 39 weeks gestation policy. This means that under no circumstances is a mama to be induced before 39 weeks gestation unless it is absolutely medically necessary; there is danger to the life of mama or baby. Otherwise, Mamas and babies have to “tough it out” to term. Additionally, many hospitals are adopting strict policies against obstetricians who perform elective inductions in an effort to deter the practice.

The results of the policy has shown the following results according to researchers Nathaniel DeNicola, MD, from the University of Pennsylvania, in Philadelphia, Andrew Healy, MD, medical director of obstetrics at Baystate Medical Center, in Springfield, Massachusetts and Angela Silber, MD, director of maternal-fetal medicine at Summa Akron City Hospital, in Ohio:

Dr. DeNicola’s Study (A Survey Study)

  • Many hospitals have adopted specific policies against elective induction
  • Nearly two thirds of more than 2600 hospitals have “no elective induction” policies in place.
  • 67% of hospitals have a formal policy against non-medically indicated labor induction, and among those without a formal policy, just over half said it was against their standard of care.
  • 69% of formal hospital policies were hard-stop, meaning strictly enforced, as opposed to soft-stop or strongly discouraged.

Dr. Healy’s study

  • Compared 9515 singleton births before the policy and 2641 singletons after the policy found a significant decrease of 5.9 hours in the median time to delivery (P = .002).
  • The cesarean section rate for elective inductions also decreased from 16% before the policy to 7% after (= .05).
  • NICU admission rates decreased by a third. Before the policy, 3% of term babies got admitted to the NICU and after the policy that went down to 2%” (= .02).
  • No increase in the stillbirth rate

Dr. Silber’s  pre- and post policy comparison

  • Decrease in stillbirths and NICU admissions
  • Comparing 9806 singleton deliveries before the policy and 6041 singletons after, the number of stillbirths decreased significantly from 16 to 3 ( = .023), with a trend toward significance in the reduction of NICU admissions (from 867 to 587; P = .06).
  • There was no significant difference in macrosomia (Large for gestational age) rates (P = .718)

Other data not fully analyzed shows a decrease in cesarean sections as well as postpartum hemorrhage.

As a result of these studies, many obstetricians and hospitals are really questioning the practice of induction and no longer performing inductions unless absolutely medically necessary. According to these researchers, this data may be what makes elective inductions history!

Summarized from MedScape News,  OB/GYN & Women’s Health by Kate Johnson, May 23, 2013

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: US Maternity Care-Living in a Glass House Throwing Stones

August 15th, 2012

I am increasingly dismayed by the fact that the US seems to think it has no maternal or infant morbidity and mortality issues. The sad truth is that the United States, in many situations surrounding maternity and childbearing, has statistics that rival many developing nations and in some cases are actually worse.

When I read various articles and news briefs, many US researchers with big money grants are reporting data from developing nations and the implications seem to be that we must reduce maternal and infant morbidity and mortality globally-i.e. “in these developing nations” to lower the global statistics. I want to go on the record asking, “How can we even begin to critique issues of maternal and infant morbidity and mortality worldwide when the US has some of the worst maternal and infant morbidity and mortality rates in the world?” In the recent blog post “Minority Mamas are More Likely to Die in Childbirth” I cited data published about maternal mortality in the United States and the disparity between women of color (primarily black women) and white women. It is one of few pieces that has actually noted and questioned high maternal mortality in black women in the United States. While it did not offer much in the way of theories as to why the rates are so unbalanced, the obvious initial steps would be to look at disparities in health care delivery in areas with a high black population and in lower socioeconomic areas.

Hold on, some of you may be saying. The US has exceptional health care, some of the best in the world. This is quite true. But not everyone in the United States has access to the exceptional health care that exists in this country. As evidenced by the heated health care reform debates, millions of Americans are without health insurance and despite the passage of the Affordable Care Act and its many provisions for women’s health care, there will still be a substantial number of people, many of them women and children, for whom our “exceptional health care” is woefully out of reach. Some will argue that saving some is better than saving none at all. Personally speaking, until everyone in this country has access to high quality health care, we as a nation have no business studying and critiquing health care practices in other countries.

In its groundbreaking work Deadly Delivery, Amnesty International shines a glaring light on the maternal morbidity and mortality issues in the United States and raises the questions are race and poverty to blame? Few if any other research groups have deigned to make the connection. But with the numbers such as they are, we are going to have to tread that road.

The United States is one of only 4 nations globally that offers no paid maternity. Out of some 178 nations, The United States, Papua New Guinea, Swaziland, and Lesotho are the only nations that offer no paid maternity leave. Of those nations, the United States is the only industrialized nation, and one of the richest nations in the world. But with all of our riches, the gap between “those who have” and “those who have not” is becoming a gaping chasm with no end to the widening in sight.

The Cesarean Section rate in the United States approximately 32% meaning that almost 1 of every 3 babies born in this country is delivered via cesarean section. This far exceeds the rate proposed by the World Health Organization (WHO) yet, we are far from finding a solution to this problem. Several maternity advocacy groups (Childbirth Connection,International Cesarean Awareness Network (ICAN) and others) are challenging the US health care system, the American Congress of Obstetricians and Gynecologists (ACOG) in particular, to take steps to turn the tide on this quelling cesarean section rate. We’re all waiting to see changes in birth policies and subsequent reduction in the national Cesarean section rates.

And then there is bed rest. How could I possibly not address one of the more controversial treatment practices in all of medicine? To date there is not solid evidence that bed rest in any way prevents preterm labor and premature delivery. We don’t have solid evidence that it in any way improves or strengthens an incompetent cervix, helps lower blood pressure or prevents any of the complications of pre-eclampsia. There is some evidence that bed rest is harmful to pregnant women and may do more harm than good. Yet annually, nearly a 3/4 of a million pregnant women are prescribed bed rest for complications of pregnancy.

I want the US to stop casting stones towards other countries for their maternity practices and to focus instead on how to lower maternal morbidity and mortality rates here at home. Until we have impeccable maternity rates and until all mamas have access to high quality health care we must focus our attention on ourselves and stop pointing fingers of criticism elsewhere.