Health Care for Women and Their Infants
Various topics have been in the forefront for obstetrical providers in the 4 years since the last edition of this textbook. Of these, the ills of our health-care system are especially concerning for women’s health (Hale, 2010). To cite but a few examples, uninsured women with breast cancer were up to 50 percent more likely than insured women to die from the disease. There were more than 17 million uninsured American women aged 18 to 64 years in 2008. Similarly, women without health-care insurance had a 60-percent greater risk of late-stage cervical cancer. Lack of medical insurance also has severe effects on pregnant women. Those without insurance have a 31-percent higher risk of adverse outcomes such as preterm delivery, neonatal death, and maternal mortality. Of American women aged 18 to 64 years in a recent study of 11 industrialized countries, 43 percent skipped seeing a doctor or did not take medicine due to costs (Robertson, 2012). This was the highest percentage of all 11 countries studied. By comparison, just 7 percent of British women and 17 percent of Canadian and French women refrained from seeking health care because of costs. Of the 11 countries studied, only the United States did not have universal health-care coverage.
There is also a geopolitical consequence of such increased adverse outcomes for American women. The World Health Organization analyzed neonatal mortality rates in 2009 for 193 countries (Oestergaard, 2011). The United States ranked 41st in 2009, dropping from 28th in 1990. The highest newborn death rate in the world was in Afghanistan, where one of every 19 babies died before their 1-month birthday. In comparison, one of every 233 newborns dies in the United States. This is far better than the rate in Afghanistan, but not as good as the rate in Japan—1 in 909, France—1 in 455, Lithuania—1 in 385, or Cuba—1 in 345. Some reasons given for the United States results include difficulty in accessing prenatal care, which contributes to the current high rate of preterm births.
There have been dramatic changes in women’s health care regarding obstetrical and gynecological procedures during the past 30 years in the United States. Shown in Figure 1-7 are the rates per 1000 adult American women for the commonest gynecological procedures performed between 1979 and 2006. The rates are adjusted for age to correct for population changes over time. The dramatic decreases in the rates of gynecological procedures were thought largely due to changed criteria for these procedures. Changed criteria resulted from the health maintenance organization (HMO) movement of the 1980s. With this, health-care insurers of all types exercised increasing control over the indications for these procedures. Shown in Figure 1-8 are the rates per 1000 adult women for obstetrical procedures also from 1979 to 2006. Episiotomy use plummeted, as did operative vaginal delivery rates. Cesarean deliveries per 1000 women greatly increased. These rates changes are discussed more fully in Chapters 27, 29, and 30, which cover these delivery routes.
Age-adjusted rates of gynecological procedures in the United States, 1979–2006. (Data from Oliphant, 2010.)
Age-adjusted rates of obstetrical procedures in the United States, 1979–2006. (Data from Oliphant, 2010.)
There are only two federal programs dedicated solely to health care of women and their infants, and every obstetrician should know about these programs (Lu, 2012). The first is the Title V Maternal and Child Health Services Block Grant, which is the only federal program focused on improving the health of mothers, children, and their families. It was enacted by Congress in 1935 as part of the Social Security Act. Title V provides for state-level block grants in which states match with $3 every $4 in federal money. In 2009, states reported that 2.5 million primarily low-income pregnant women and 35 million children were served by these state block grants.
The second federal program dedicated to women’s health care is the Title X Family Planning Program. This is the only federal program focused on providing women with comprehensive family planning and related preventative health services. Title X was enacted in 1970, and in 2010, it served more than 5.2 million primarily low-income women.
Beginning with implementation of the 2003 United States Standard Birth Certificate described earlier, the principal source of payment for births was reported. In 2010, it was estimated that Medicaid financed 48 percent of the births in the United States (Markus, 2013). Importantly, Medicaid covered a disproportionate number of complicated births. Specifically, Medicaid paid for more than half of all hospital stays for preterm and low-birthweight infants and approximately 45 percent of infant hospital stays due to birth defects.
So, what is the “bottom line” for obstetrical health care in the United States for women and their infants? In 2008, the total national hospital bill was almost $1.2 trillion (Wier, 2011). These charges involved 39.9 million hospital stays but do not include outpatient care, emergency care for patients not admitted to the hospital, or physician fees. Medicare and Medicaid paid for 60 percent of the 2008 national hospital bill. Specifically, Medicare covered 46.2 percent and Medicaid 13.8 percent. The hospital bills for the mother’s pregnancy and delivery plus care of the newborn exceeded $98 billion, representing 8 percent of all hospital bills. This bill for women and their infants is more than twice that of any other diagnosis across the entire spectrum of American health care and attests to the impact of health care for pregnant women in this country.
In the last edition of Williams Obstetrics, the Obama Administration was poised to pass universal health insurance—so-called Obamacare. This history-making legislation debuted on March 23, 2010, with passage into law of The Patient Protection and Affordable Care Act—PPACA. Although constitutional challenges followed, the Supreme Court upheld most aspects of the law in its ruling in 2012 of National Federation of Independent Business v. Sebelius. Implementation of this complex legislation began in 2010 and will continue over the current decade (Fig. 1-9). Indeed, initially registration began with a rocky start in late 2013.
Timeline for implementation of provisions of the Patient Protection and Affordable Care Act. (From Oberlander, 2012, with permission.)
As outlined by the Society for Maternal-Fetal Medicine, the act will expand obstetrical care of indigent women (Grande, 2013). The American College of Obstetricians and Gynecologists (2013a) estimates that nearly 20 million uninsured women aged 18 to 64 years have less than optimal access to prenatal care, family planning services, and breast and cervical cancer screening. Many of these women will have improved access to these services because of the expanded Medicaid coverage funded through the Act. The College encourages individual states to expand their Medicaid coverage and improve reimbursement rates.
One “fly in the ointment” of the Affordable Care Act is funding. Although it has been declared “budget neutral,” the Congressional Budget Office has calculated that 30 million Americans will remain uninsured. For these and a multitude of fiscal reasons—and we certainly do not profess to be economists—we, like Oberlander (2012) and others, remain nervous concerning costs and adequate funding for “universal health care.”
Rising Cesarean Delivery Rate
In 2009, the cesarean delivery rate climbed to the highest level ever reported in the United States—32.9 percent (Centers for Disease Control and Prevention, 2013). After that, it appears to have stabilized. This rise in the total rate was a result of upward trends in both the primary and the repeat cesarean delivery rates. Indeed, more than 90 percent of women with a prior cesarean delivery now undergo a repeat procedure. The forces involved in these changes in cesarean delivery rates are multifactorial and complex. We cite a few examples:
The major indication for primary cesarean delivery is dystocia, and there is evidence that this diagnosis has increased. This is discussed in Chapter 23 (Dystocia).
The sharp decline in vaginal births after cesarean (VBAC) delivery is closely related to the uterine rupture risk associated labor with a prior uterine incision. This is discussed throughout Chapter 31.
The controversial cesarean delivery on maternal request (CDMR) contributes to the rise. This is defined as a cesarean delivery at term for a singleton pregnancy on maternal request in the absence of any medical or obstetrical indication (Reddy, 2006). This is discussed in Chapter 30 (Patient Preparation).
Near-term and term pregnancy labor induction is commonplace, and failed inductions contribute to the cesarean delivery rate. This is discussed in Chapter 26 (Risks).
It is not possible to precisely measure the contribution of each of these components to the all-time-high cesarean delivery rate. The American College of Obstetricians and Gynecologists and the Maternal-Fetal Medicine Units Network have addressed these in an attempt to curtail the rising rate. The National Institute of Child Health and Human Development convened a State-of-the-Science Conference in 2006 to provide an in-depth evaluation of the evidence regarding cesarean delivery on maternal request. To date, there have been no evidence-based guidelines. Recognizing that repeat operations constitute a large percentage of cesarean deliveries, the National Institutes of Health (2010) convened a consensus conference entitled Vaginal Birth after Cesarean: New Insights. The findings are discussed in detail in Chapter 31 (100 Years of Controversy), but to summarize, they supported a trial of labor for many selected women with a prior cesarean hysterotomy scar and recommended that this option be made more available. It is too early to conclude if this recommendation has significantly altered the cesarean delivery rate.
Recent breakthroughs in fetal testing and diagnosis are truly stunning. In one recent issue of the New England Journal of Medicine, there were three reports in which prenatal gene microarray techniques were used for clinical management (Dugoff, 2012). The advantages of these techniques are outlined in Chapters 13 and 14. Wapner and coworkers (2012) compared microarray analysis of maternal blood with karyotyping for chromosomal anomalies. Reddy and associates (2012) applied this technology to stillbirth evaluation and reported it to be superior to karyotyping. The third report by Talkowski and colleagues (2012) described whole-genome sequencing of a fetus using maternal blood.
Added to these possibilities is the specter of made-to-order embryos (Cohen, 2013). These are but a few examples that illustrate the power of genomic technology to pursue fetal diagnosis and possible therapy. At this juncture, there are complex obstacles to overcome, but with rapid advancement of these technologies, success is almost assured.
Electronic Health Records
Rising costs, inconsistent quality, and patient safety issues are significant challenges to the delivery of health care in the United States. Electronic health records (EHR) have been identified as a means of improving provider efficiency and effectiveness (Jha, 2009). Methods to speed the adoption of health information technology have received bipartisan support in Congress, and the American Recovery and Reinvestment Act of 2009 has made such a system a national priority. This was soon followed by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Recent surveys indicate that approximately half of outpatient practices and hospitals in the United States are now using EHR. This act also introduced the concept of “meaningful use” EHRs by providers. Classen and Bates (2011) appropriately note, however, that “meaningful use” does not necessarily equate with “meaningful benefits.” According to the American College of Obstetricians and Gynecologists (2010), studies of effectiveness are critically needed to justify the safe implementation of these costly electronic computerized systems.
Health-Care Outcomes Research
Although per capita health-care expenditures in the United States are the highest in the world, health-care outcomes frequently lag behind those in nations spending far less. A major factor in this disparity is thought to be expenditure overuse, underuse, and misuse driven by rationale-based instead of evidence-based health care. Buried within the 2400 pages of the landmark health-care reform bill signed into law by President Barack Obama are several provisions that touch on clinical research (Kaiser, 2010). Two are aimed at determining which health-care interventions work best and identifying financial conflicts of researchers. A third provision funds acceleration of new drug development. Proponents hope these research studies will improve the quality and lower the cost of health care by identifying the best treatments. We applaud this effort. Indeed, we are of the view that systematic prospective measurement of health-care outcomes as related to treatments prescribed should be an on-going requirement for the practice of medicine.
Much publicity followed the report by the Institute of Medicine entitled To Err Is Human (Kohn, 2000). This report greatly increased interest in measuring health-care outcomes and adverse events (Grobman, 2006). Even the United States Congress has determined that reimbursements by Medicare and Medicaid should be indexed to selected health-care outcomes. Specifically, a wide, often dizzying spectrum of benchmarks has been proposed to measure the quality and safety of obstetrical care. In our view, the greatest impediment to deriving meaningful measures of obstetrical care is the continued use of administrative and financial data—instead of clinical data—to set benchmarks for outcomes.
Regulatory bodies typically evaluate hospital quality using obstetrical outcomes derived from administrative (financial) datasets not designed to measure clinical results. Accordingly, the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development undertook an unprecedented and unparalleled study of obstetrical outcomes based on carefully collected clinical data (Bailit, 2013). The purpose was to establish risk-adjusted models for five obstetrical outcomes and then determine if hospital performance could be reliably measured so that hospitals could be compared. Outcomes studied included postpartum hemorrhage, peripartum infection, severe perineal laceration, neonatal morbidity, and venous thromboembolism. This study included 115,502 mother-infant pairs managed for 3 years at 25 hospitals. Clinical data were abstracted from medical records by specially trained research nurses using a prespecified manual of operations. The study clearly demonstrated that differences between obstetrical outcomes at different hospitals, when clinically adjusted for preexisting patient characteristics, cannot be used to accurately compare obstetrical care among hospitals.
So, what does this mean? It means that the widespread current practice of ranking obstetrical care at different hospitals based on single outcomes, such as third- or fourth-degree perineal lacerations, is useless when accurate data are used. Moreover, use of up to four obstetrical outcomes did not improve the ability to rank hospitals. Actually, use of more than one outcome greatly confused the ranking. A given hospital might rank number one out of 25 hospitals for one obstetrical outcome and 25 out of 25 for a second outcome. Thus, a given hospital could be both very good and very bad depending on the obstetrical outcome analyzed!
Approximately 12 percent of obstetrician-gynecologists had at least one malpractice claim each year from 1991 through 2005 (Jena, 2011). The American College of Obstetricians and Gynecologists periodically surveys its fellows concerning the effect of liability on their practice. The 2012 Survey on Professional Liability is the 11th such survey since 1983 (Klagholz, 2012). The survey reflects experiences of more than 9000 members, and 58 percent of these fellows responded that some aspect(s) of the liability environment had caused them to alter their practice since the last survey. Undoubtedly not all of these changes were positive. Those cited included an increased cesarean delivery rate, fewer trials of labor after a prior cesarean delivery, and a decreased number of high-risk patients and total deliveries (Amon, 2014). Others have chosen to forego obstetrical practice entirely. Some of these changes have been linked to states with higher liability premiums (Zwecker, 2011).
Thus, by all accounts, there is still a “liability crisis,” and the reasons for it are complex. Because it is largely driven by money and politics, a consensus seems unlikely. Although some interests are diametrically opposite, other factors contribute to the complexity of the crisis. For example, each state has its own laws and opinions of “tort reform.” Meanwhile, liability claims remain a “hot button” in obstetrics because of their inherent adversarial nature and the sometimes outlandish plaintiff verdicts that contribute to increasing liability insurance premiums. In some states, annual premiums for obstetricians approach $300,000—expenses that at least partially are borne by the patient and certainly by the entire health-care system. Liability issues are daunting, and in 2008, all tort costs in the United States totaled nearly $255 billion. This is an astounding 1.8 percent of the gross domestic product and averages $838 per citizen (Towers Perrin, 2009). Annas (2013) has provided an interesting review of two centuries of malpractice law history. Interestingly, he compares medical malpractice litigation to the white whale in Melville’s Moby-Dick—evil, ubiquitous, and seemingly immoral!
The American College of Obstetricians and Gynecologists has taken a lead in adopting a fair system for malpractice litigation—or maloccurrence litigation. The Committee on Professional Liability has produced several related documents that help fellows cope with the stresses of litigation, that provide advice for the obstetrician giving expert testimony, and that outline recommendations for disclosure of any adverse events (American College of Obstetricians and Gynecologists, 2013c,d,e).
National liability reform likely will come in some form with the push for universal medical insurance coverage. President Obama, in his 2009 address to the American Medical Association, indicated that national malpractice liability reform was negotiable. United States Congressman Michael Burgess—an obstetrician-gynecologist—asked the president to reaffirm this commitment. We applaud these efforts and wish for their success.
Following a slight decline from 1990 through 2004, according to the National Center for Health Statistics, the percentage of home births in the United States increased from 0.56 to 0.72 percent—almost 70 percent—through 2009 (MacDorman, 2012b). But, as is so often the case with data analysis, the “devil is in the details.” Only 62 percent of these 24,970 home births were attended by midwives—19 percent by certified nurse midwives and 43 percent by so-called lay midwives with minimal formal training. The remaining 38 percent of home births were unplanned—that is, the result of accidental delivery at home attended by a family member or emergency medical technician. So is home birth a good idea? Those currently conducted in the United States in which women are not attended by trained and certified personnel cannot be considered acceptable. There have been no randomized trials to test the safety of home deliveries (Olsen, 2012). Proponents of home births cite success from laudatory observational data from European countries such as England and The Netherlands (Van der Kooy, 2011). Data from the United States, however, are less convincing and indicate a higher incidence of perinatal morbidity and mortality (Grünebaum, 2013, 2014; Wasden, 2014; Wax, 2010). These findings have led Chervenak and coworkers (2013) to question the ethics of participation in planned home births.
Politics and religion over the years have led to various governmental interferences with the reproductive rights of women. These intrusions have disparately affected indigent women and adolescents. One example was the consideration by Congress in 1998 for the Title X Parental Notification Act. Reddy and colleagues (2002) estimated this bill would have dissuaded almost half of adolescents younger than 17 years from seeking contraceptive services and care for sexually transmitted disease.
Another example is the tug-of-war over emergency contraception, and more specifically over the morning-after pill (Chap. 38, Emergency Contraception). Efforts begun in 2004 by the Bush Administration to curtail Plan B for over-the-counter sales to women 17 years and younger was decried appropriately by editorials in the New England Journal of Medicine (Drazen, 2004; Steinbrook, 2004). This issue was not settled until April 2013 when a federal district court in New York ordered the Food and Drug Administration to make emergency contraception available for over-the-counter sales to all women regardless of age. The decision was quickly applauded by the American College of Obstetricians and Gynecologists (2013f). The decision was editorialized as “science prevails” in a subsequent issue of Nature (2013).
Perhaps the most egregious example of both federal and state governmental intrusion into women’s reproductive rights is the often poor availability of federally funded family planning services for indigent women. This is despite all reports of the overwhelming success of such programs. According to the Guttmacher Institute, publicly funded family planning services in 2010 prevented nearly 2.2 million unintended pregnancies and 760,000 abortions in the United States. They concluded that without such funding the abortion rate would be nearly two-thirds higher for all women, and nearly 70-percent higher for adolescents (Frost, 2013). The American College of Obstetricians and Gynecologists (2012) has recently reviewed these and other barriers to emergency contraception access.
It continues to be a preventable fact that up to a fifth of pregnancies in this country are terminated by elective abortion (see Table 1-1). According to the American College of Obstetricians and Gynecologists (2011): “The most effective way to reduce the number of abortions is to prevent unwanted and unintended pregnancies.” Importantly, the negative attitudes, beliefs, and policies toward family planning services and sex education discussed above have helped to contribute to the more than 800,000 abortions performed yearly in the United States.
The history of legislative regulation and federal court decisions regarding abortions is considered in Chapter 18 (Induced Abortion). The Partial Birth Abortion Ban Act of 2003 has become law, and in 2007, the Supreme Court ruled that the ban—officially known as Gonzales v. Carhart—is constitutional. This again caused editorialists in the New England Journal of Medicine to decry the intrusion of government into medicine (Charo, 2007; Drazen, 2007; Greene, 2007). More ominous are restrictive state laws—many of which have been or will be ruled unconstitutional—which according to some will drive Roe v. Wade back to the Supreme Court.