A multi-part series originally posted on HealthCare_2.0
INTRO ~ Overview, Background & Goals
(note ~ article updated April 24, 2013)
Whatever one’s individual opinion about the nature of childbirth practices in the US, both professionals and consumers agree that the current maternity care system is far from ideal — we spend far too much and get much too little. To be precise, the US spends 98 billion dollars annually — that’s billion with a “B” — on hospitalization for pregnancy and childbirth — twice as much as any other on country.
In particular our country spends more on childbirth-related hospitalization than any other hospital-based service provided in American hospitals. Our C-section rate is essentially 33%. Since Cesarean surgeries are twice as expensive as normal childbirth, the overuse of operative delivery accounts for more than its fair share of that $98 billion bill.
Over 1.3 million Cesarean surgeries are performed annually, which is approximately the same number as college students that graduate each year in the US. The rate for Cesareans is more than double that for all other operations and other procedures performed in a sterile environment. A healthy childbearing woman in the prime of life is more likely to see the inside of an operating room than someone who is acutely ill, elderly or injured.
How can such a technologically sophisticated system that serves a remarkably healthy childbearing population in one of the world’s wealthiest countries be 1st in spending while ranking 50th in the rate of maternal mortality? That means 49 other, mostly less wealthy countries have a much lower rate of mothers dying during or after they give birth than the USA. The April 24th, 2013 Huffington Post’s subtitle was “Dying to Have A Child“. The article notes that the our MMR had DOUBLED in the past 25 years. Interestingly enough, so has our Cesarean section rate.
The fundamental question is why our maternity care system is so dysfunctional?
What are the forces that created such highly medicalized system of obstetrical care for healthy women?
Equally if not more important is the positive aspect of the issue. What are the essential qualities of a maternity care system designed to provide cost-effective care to healthy women with normal pregnancies? How do we identify the characteristics of success when it comes to safety? What professions, places and policies make for the best maternal-infant outcomes? When it comes to the 70% of American women who are healthy and have normal pregnancies, there is the question of whether governments, other 3rd party payers and those who must pay out-of-pocket are getting an appropriate ‘bang for their buck’. Is the current configuration of medical and midwifery care making the kind of cost-effective contribution that economists refer to as ‘value added’?
Relative tothe price paid, ‘value-added’ describes the positive contributions of a service that is suppose to make something “better” that it would be without that particular set of services. To identify that quality in maternity care, we must first be able to determine the innate risky-ness of normal childbearing and then track the same outcome criteria for all categories of birth attendants and all birth settings. As a result, the relative benefits of each category of maternity care can be directly quantified without falling back on place-of-birth as a proxy for anything else. This is the most direct way to establish the manner and magnitude of medicine and midwifery’s ability improve maternal-infant outcomes in a safe and cost-effective fashion.
The passage of health insurance reform legislation in the US makes it even more crucial to determine if what we are doing – the theories, policies and practices developed early in the 20th century – is the best configuration for maternity care in the 21st century.
Minding the Gap: In an effort to address those questions, this commentary takes a fresh look at our aging 20th century maternity care system and the 21st century debate about its reform. At the heart of this controversy are two pivotal issues: ‘place-of-birth’ as proxy for the efficacy of intrapartum management and the lack of ‘standard care’ characteristics among birth attendants and birth settings.
Our current configuration of childbirth services is a smorgasbord of non-standard care characteristics as provided by midwives, family practice physicians and obstetricians in a variety of small, medium and large hospitals and in OOH settings that include independent birth centers and planned home birth (PHB). When combined with the economic and political complexities of modern healthcare, this unsystematic system creates a large gap between what is known about ‘best practices’ and what is consistently being provided to childbearing women and paid for by us all.
Of these two issues, the controversy over place-of-birth has made the most mischief and continues to direct our attention to a set of questions that, as currently formulated, cannot be answered. A hundred years after this brouhaha started, it continues to distract us from the questions about childbirth safety that can be answered.
Evaluating ‘quality of care’ & ‘standard’ vs. ‘non-standard’ care characteristics of practitioners & facilities:
An abundant source of data is already available, including studies provided in this commentary. This type of information can and should be used to rationally evaluate quality of care issues and standard care characteristics by distinguishing effective forms of care from customary practices that are not directly associated with better outcomes for mothers, babies and those who pay the bill.
The necessary precursor to safe and cost-effective maternity care in North America lies is distinguishing between safe and unsafe practices in each setting and for each type of birth attendant. This allows the essential qualities of maternity care to be determined and standard characteristics of practice be developed for all places and persons provide maternity care to health women.
To do that, evidence-based policies and a consensus for action must be developed among all stakeholders – childbearing parents and consumer activists, birth attendants, other maternity care professionals, hospitals, 3rd party payers and public health officials. The goal is nothing less than an integrated, cooperative and ‘minimalist’ model based on “best practices”.
To paraphrase from a popular religious text: “Who among you if his child should ask for bread, would give instead a stone?” We must make sure the maternity care system does not unintentionally offer a stone in place of kindly extended helping hand.
Link to next in series ~ Part 2: The Optimal Purpose of Maternity Care
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