Childbirth -- Can the US improve?
Should taxes pay for unnecessary hospital procedures?
Are some operations for the patient or for the doctor’s pocket? And those are the guys who resist competition from midwives. Would socialized medical attention improve the situation? This 2009 article is from the Los Angeles Times, May 17.
by Lisa GirionWith a surge in caesarian births has come an explosion in medical bills, an increase in complications -- and a reconsideration of the procedure as a sometimes unnecessary risk.
It is an example of how US brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.
As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation's $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.
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.)
Pregnancy is the most expensive condition for both private insurers and Medicaid.
The cesarean rate in the US is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the US has set a new record every year for more than a decade.
The cesarean -- delivery via uterine incision -- exposes a woman to the risk of infection, blood clots, and other serious problems. Cesareans also have been shown to increase premature births and the need for intensive care for newborns. Even without such complications, cesareans result in longer hospital stays.
Inducing childbirth -- bringing on or hastening labor with the drug oxytocin -- also is on the rise. Experts say miscalculations often result in the delivery of infants who are too young to breathe on their own. Induction also raises the risk of complications that lead to cesareans.
Despite all this intervention -- and, many believe, because of it -- childbirth in the US lags behind other developed nations on key performance indicators including infant mortality and birth weight.
And in at least two areas, the US has lost ground after decades of improvement: The maternal death rate began to rise in 2002, and the typical American newborn is delivered at 39 weeks, down from the full 40. Public health experts view the trends with alarm.
"Cesarean birth ends up being a profit center in hospitals, so there's not a lot of incentive to reduce them," said Dr. Elliot Main, chief of obstetrics for Sutter Health, a Northern California hospital chain.
But there is a lot that hospitals can do to reduce them, as illustrated by the wide variation in cesarean rates. 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."
The surge in cesareans may owe more to celebrity magazines than medical journals. After word got out that Victoria "Posh Spice" Beckham had three, physicians reported a surge in requests for such deliveries, dubbed the "too posh to push" bump.
Physicians, too, have been blamed for failing to make women fully aware of the consequences of cesareans, and for promoting them for convenience.
But change is underway. The Institute for Healthcare Improvement's Strategic Partners program trains hospitals to implement a set of guidelines, such as the careful use of oxytocin, and a ban on elective deliveries before 39 weeks. In four years, 60 hospitals have signed on.
WellPoint Inc. and UnitedHealthcare Services Inc., the nation's largest health insurers, also are trying to curb cesareans.
In an analysis of its claims, United found that 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.
United targeted a group of Texas obstetricians with particularly high rates of deliveries before 39 weeks.
An analysis showed that the babies these doctors delivered were admitted to neonatal ICUs twice as often as the national average.
After being notified of the correlation, the physicians changed their practices and reduced neonatal ICU admissions by 46% in three months.
The rise in avoidable first-birth cesareans has had a multiplier effect. Most US physicians discourage vaginal deliveries after a cesarean because of some widely publicized cases several years ago in which the uterus split disastrously along the prior incision.
But some obstetricians believe that new evidence supports allowing some women the option of trying for a vaginal birth if the incision is in the bottom part of the uterus, from side to side. Those heal better. All the studies say, in those types of incisions, the risk is less than 1%, probably a half percent, that it will open during labor.
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