Impact of historical events on taxpayers, state budgets & the federal deficit ~ part 2-b (of 4)

link back to part 2-a

Our current model of maternity care for healthy women is the product of the historical events already recounted in this document.

Over the last 50 years the rate of medical and surgical interventions in normal childbirth has climbed steadily without a comparable improvement in outcome. Each decade new ideas, new drugs, new technologies are added, while the encrustations of previous decades are preserved as the foundation of “customary care” and a hedge against claims of medical malpractice. All indicators point to the indefinite continuation of this trend.

Obstetricians are generally satisfied with their modern role, which is to supervise the endless convey belt of childbearing women. Under their authority, each laboring woman is cared by a variety of nurses acting under ‘doctor’s orders’. The job os these hospital employees is to dutifully administer many drugs and employ different kinds of medical devices.

Modern L&D nurses are forced to become specialists in managing electronic fetal monitors, a technology that is both central to the medical management of modern childbirth care and like a baby (or a beta product) constantly in need of being ‘tweaked’ in order to work properly. The L&D staff often spends more time ‘nursing’ the EFM than the mother-to-be.

All of these medical activities are an effort to ‘cure’ laboring women of pregnancy as quickly as possible, via the use all means possible, including Cesarean section. Of course, the one exception is providing physiologically care and one-on-one support by the mother’s primary birth attendant.  A popular obstetrical journal published a comment by an obstetrician in 1992 that clearly identifies the past, present and future direction of the obstetrical profession in that regard:

“It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.” [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].  

Since the early 1970s, the Cesarean section rate has risen from 5% (1 in 20)  to 32.8% (1 in 3). This high C-section rate is associated with a relative increase in maternal deaths associated with the immediate, delayed and long-term complications of this major abdominal operation.

The most costly interventions and those most associated with iatrogenic and nosocomial complications are:

  • continuous electronic fetal monitoring in low and moderate-risk pregnancies
  • induction of labor as a pre-emptive strategy based solely on due-dates, convenience or other non-medical reasons
  • liberal use of Cesarean section in healthy populations of childbearing women

The well-known and highly respected Maternity Center Association of NYC has been serving low-income women and lobbying for safe and affordable maternity care policies since 1918. Recently renamed “Childbirth Connection” , this advocacy organization conducted a series of surveys called “Listening to Mothers” in 2002, 2004 and 2006.

Their researchers interviewed essentially healthy women who had normal term pregnancies (no medical complications or prior C-sections, no breech babies, twins or premature births) to determine the quality of care these women received, number and frequency of interventions and the level of satisfaction with the type of maternity care received. Thousands of new mothers filled out lengthy questionnaires that provided a snap-shoot of how the 1910 plan for the universal medicalization of normal childbirth was working out for the pregnant women who continue to give birth under its ministrations.

According to “Listening to Mothers” data, this 100-year old model of obstetrical care for healthy women has become even more medicalized as we’ve gone through time.  Typically a normal labor and birth in women with no prior medical issues for mother or baby includes seven or more medical or surgical interventions. In this survey approximately 70% of these healthy childbearing women reported some form of surgical procedure or operative delivery — episiotomy, forceps, vacuum extraction or Cesarean surgery.

Continuous electronic fetal monitoring (EFM) was introduced in the mid-1960s. Obstetricians hoped this new technology would provide them with an early warning system that could prevent babies from developing cerebral palsy. By 1980, continuous monitoring had become the standard for all women in labor. EFM is billed at $400 an hour and used in 93% of all hospital labors, even though all the studies ever conducted on the routine use of EFM in normal pregnancies were unable to confirm any improved outcomes for either mother or babies.

The only  consistently documented effect of EFM was an increased rate of Cesarean surgeries.

Despite the significant additional expense of continuous monitoring, EFM has been unable to lower the CP rate by even the tiniest smidgen. This was officially acknowledged by the obstetrical profession nearly a decade ago, when they published materials stating these facts for the purpose of providing a dissenting opinion in malpractice cases based on EFM strips that claim to prove that the obstetrician’s failure to perform a ‘timely’ Cesarean caused their baby’s cerebral palsy.

Nonetheless, EFM remains a mainstay of obstetrics. Hospital risk managers continue to insist that the printout or electronic record of EFM tracings is their best defense in case of a malpractice suit. However, billing 93% of one’s laboring patients at $400 an hour for their entire labor (as much as 48 hours for women being induced) may be part of the incentive to preserve this tradition.

Labor induction rates have likewise sky-rocketed. This is often a two-day medical procedure, especially for first-time mothers, and is associated with increased Cesarean rates. Many hospital obstetrical units have a policy known as “Pit to distress” — that is, a protocol to intravenously administer the hormonal drug Pitocin (it induces or speeds up labor) in increasingly large doses until the mother either delivers vaginally, or the baby goes into fetal distress and has to be delivered by emergency Cesarean section. Personally, I consider “Pit to distress’ to be a criminal practice of medicine.

In 1996, the Cesarean rates in the US were 20.7 percent. Having risen from 5% in 1970, a 21% C-section rate was consider by many to be scandalous. This triggered much handringing and debate about how control our out-of-control surgical delivery rate. That same year,  the Medical Leadership Council, which is an association of over 2,000 hospitals in the US) concluded that our cesarean rate was:

 “medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”

“..beyond any individual’s power, purview or interest to correct” was a prophetic observation, as Cesarean delivery is now the most commonly performed surgical procedure in the United States, and it numbers continues to increase annually. C-section is also the most common operating room procedure performed among all patients in US hospitals.

This last number is even more chilling, as it describes diagnostic procedures. These are not surgeries at all in the since of an operation, but merely the use of technology under sterile conditions. Examples are angio-catherizations and similarly ‘invasive’ radiology procedures. This number means that more healthy women are having major abdominal surgery than elderly and ill patients who need diagnostic procedures.

The Cesarean rate reached an all-time high in 2011 of 32.9 %. Today it is essentially unchanged at 32.8%. Some American hospitals have a 69.9 percent rate (i.e., 70%). The  per-hospital mean rate for annual Cesarean surgeries performed is 1,378.  But of the 593 hospital studied,  270 American hospitals perform an average of 11,971 C-sections every year. That’s a 1,000 Cesarean surgeries a month, which is 250 a week or 35 cesareans a day. The surgical delivery rates between hospital varies by ten — from 7.1 percent to 69.9 %. However  there was a fifteen-fold difference cesarean rates for women with lower-risk pregnancies. In many hospitals,  36.5% of their healthy pregnant women have their baby delivered by major abdominal surgery.

When compared to similar countries worldwide, the US cesarean rates exceeds them without any measurable clinical benefit. A recently published study on the inter-hospital variations in C-section rates noted that the vast differences between hospital is not primarily based on maternal-fetal health issues, but are instead the result of practice patterns, that is, physician preference and/or hospital policies. The study concluded that “practice patterns” are “driving the costly overuse of cesarean delivery in many US hospitals”.

Surgical delivery is twice as expensive as normal birth, and is associated with increased rates of very serious sometimes fatal complications — hemorrhage, emergency hysterectomy, infection, anesthesia complications, stroke, cardiac failure, blood transfusions, prolonged care in the ICU.

This makes maternity care the number one generator of income for hospitals and hands-down winner of the lottery for subverting the idea of healthcare for people that have medical needs into a ‘profit center’ for acute-care institutions.  Since Medicaid pays for nearly half of US births in the US, this had created a tidal wave of wealth transferred annually from taxpayer to the hospital industry.

These shocking high numbers and dubious practices are apparently what happens when a large, complex and expensive system enjoys “regulatory capture” for an entire century. Some people point to this as a medical monopoly. In modern times, this same unbridled entity has successfully avoided transparency as hospitals and doctors don’t generally have to publish their practices or their medical-surgical intervention rates. They also have no public oversight of their quality of care, and they have no accountability for outcomes except fiduciary issue that affect executive pay or shareholder value.

Nice work if you can get it.

Topic continues ~ part 3 ~