Sunday, May 17, 2009

Going in the Wrong Direction

The Los Angeles Times actually had a pretty decent article recently about the strong rise in childbirth-related healthcare costs, and declining U.S. childbirth outcomes. You can read it here.

Even if you are not pregnant or will not ever have children, this is an important article to read because the topic affects your bottom line....your pocketbook.

The article makes the important point that our increasing use of interventions like induction and cesarean sections are driving up our healthcare costs enormously while not improving outcomes. Indeed, some outcomes are actually going downhill.

Childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

"We're going in the wrong direction," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the "perinatal paradox," in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, "is a microcosm of the entire medical enterprise."

Too Many Cesareans

The article discusses how the rising cesarean rate in particular is driving up healthcare costs and resulting in poorer outcomes.

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.

One of the more interesting points the article made was how much depends on your choice of birthplace. You really shouldn't just choose the hospital closest to you. Your chances of interventions like a cesarean varies dramatically, depending on which hospital you go to.

Among California hospitals, cesareans range from 16% to 62% of births. Such variation means a lot of women are getting unnecessary cesareans, Main said. "There's no justification for that kind of variation." [emphasis mine]
Of course, you can decrease your risk for cesareans even more by choosing an out-of-hospital birth, which more and more women are recognizing as a reasonable alternative (and which has been endorsed by the Royal College of Obstetricians and Gynaecologists in the U.K. as a reasonable choice for women with uncomplicated pregnancies).

Or you can select a hospital care provider who follows the midwifery model of care, which emphasizes proactive prevention of problems, de-emphasizes use of interventions such as inductions, individualizes care based on each woman's needs, and sees labor and birth as a normal physiological process instead of a disaster waiting to happen.

Some doctors follow tenets of the midwifery model of care, and not all midwives follow the midwifery model. You can't always tell a provider's philosophy by their title or degree, so it's not simply a matter of choosing always choosing a midwife, and of course, some women have complications or special needs that necessitate seeing a doctor.

But if you ask careful questions and choose a provider that practices from the midwifery model, whatever their title, chances are much higher of you avoiding unneeded interventions and having a spontaneous vaginal birth.

Too Little Support For VBAC

The article also discusses how doctors frequently limit women's access to Vaginal Birth After Cesarean, or VBAC.

The International Cesarean Awareness Network (ICAN) did a telephone survey this year of virtually all the hospitals in the United States and found that nearly half did not permit VBACs, either by outright policy ban or because no doctors at the hospital would take a VBAC.

In fact, even in the hospitals that in theory "permitted" VBACs, few actually had many VBACs occur, which means that their "support" for VBACs was mostly theoretical and in reality, most mothers were talked out of a VBAC.

Based on the comments ICAN received in the survey, they estimated that only about 10% of hospitals contacted were truly VBAC-supportive, where women would actually have a reasonably good chance of having a VBAC. That's the apalling state of VBAC in this country today.

Consider the healthcare implications of this. If the rate of cesareans in first-time mothers is strongly increasing, and if most doctors do not support VBAC anymore, that means that nearly all those mothers will be having repeat cesareans for any subsequent children. It doesn't take long for that to really add up.....and for the related costs to add up too.

The lack of access to VBAC for most women means that a lot of unnecessary repeat cesareans are being performed all over the U.S., and that's another reason why our healthcare costs are spiraling completely out of control.

Even when there are no complications, the hospital stay for a cesarean is twice as long, and the costs for all the services needed are higher. Add in complications such as wound infections, blood clots, hemorrhage, and breathing issues for the baby (all of which are higher with a cesarean), and all these cesareans are really costing a lot. As the article notes:

Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)
So not only does the rising primary cesarean rate cost our healthcare system dearly, the fact that few hospitals currently support VBACs will continue to cause a rebound effect, driving the cesarean rate (and our healthcare costs) even higher in years to come.

Too Many Early Deliveries

Another important point the article made is the trend to deliver babies earlier and earlier.

The average pregnancy lasts between 38-42 weeks, with 40 weeks being considered the official "due date." But the length of the average pregnancy has declined, according to the article, and is now just 39 weeks.

Yet early delivery often creates problems with babies that just aren't quite ready to be out in the world yet. Babies born even just a little too early can have trouble with their breathing, with maintaining a stable blood sugar, with nursing effectively, and with neonatal jaundice. This means they often go to the Neonatal Intensive Care Unit (NICU), and that drives up healthcare costs. From the article:

In an analysis of its claims, United[Healthcare Services Inc.] found that 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.
One of the best ways to start reducing maternity costs is to decrease the rate of early inductions and cesareans. This should start from the top-down, from institutional policies, but until those institutions really start reforming their practices, it can start with mothers refusing early interventions that are not truly medically necessary. Even better, it can start with women refusing to choose a provider likely to order such early interventions.

The Burden of Rising Maternity Costs

Rising maternity costs are taking up an increasing proportion of the already over-bloated healthcare budget in the U.S., and will only continue to rise as the rates of interventions like cesareans go up. In an increasingly stressed economy, this makes no sense.

Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.

"The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large," the report said. "Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets."
It is time for some healthcare reform, and one of the first places to start is in the maternity care system and the skyrocketing rates of inductions and cesareans.

Even if you never plan to have children, pressing for childbirth reform is in your own best interest because of the ultimate impact of an out-of-control cesarean rate on healthcare costs that you will have to help shoulder.

It's time to press for institutional change, for policies that strongly discourage early delivery, for policies that discourage induction for convenience or for "soft" indications, for policies that strongly discourage unnecessary cesareans, and to demand that hospitals honor women's right to access VBACs.

And for those who plan to have children, we as consumers can drive this maternity care reform by voting with our feet.

We can demand that hospitals and doctors be required to report their cesarean rates to the public, we can boycott hospitals and doctors with high cesarean rates (and let them know why we are not choosing them), we can refuse to allow early and unnecessary interventions, and we can choose a provider that follows the midwifery model of care to lessen our risks of costly procedures like inductions and cesareans.

Childbirth care and outcomes are indeed going in the wrong direction in many ways, and it's up to all of us to help change that trend.


Evan and Clover and Co. said...

Excellent discussion on these issues. I gave birth to my first daughter in Alaska in a free-standing birth center. Since then, I have birthed two children in NY state, where I have no access to midwives willing to do home birth, and no birth centers. From both a financial and emotional standpoint, I feel we need to drastically increase the choices for mothers with "normal" pregnancies-- and the term "normal pregnancies" needs to have a larger umbrella. Being a week "overdue" is STILL a normal pregnancy!

Anonymous said...

This article made me think of your blog:

(Even without the basic idea that large women having babies is humorous weird news, they flatly state that large women generally cannot get pregnant.)

Anonymous said...

I love this! But too often I have heard that limiting unnecessary interventions (inductions, scheduled sections, etc.) limits womens choices! Sure you have the freedom to choose how to give birth (if at all), however, I have the freedom not to have to pay for it!

Also, I was just reading an article about the rise in abortion due to the economy, and one woman quoted in the article chose an abortion because she couldn't afford to give birth because she didn't have insurance (and I assume didn't qualify for assistance). This was a middle class woman who planned a second pregnancy with her husband, who then lost his job, not an irresponsible woman who didn't take precautions. My first thought was, why didn't her doctor talk to her about home-birth? They estimated that it would have cost $30K for a hospital delivery, when a home birth might have cost 80% less. Making options more available may have saved a baby's life, in this case.