Strollerderby : induction

Should Healthcare Reform Start in the Maternity Ward?

Madeline Holler — Tue, 19 May 2009 18:01:00 GMT

While the Obama administration tries to hammer out healthcare reform -- one based, necessarily, on reducing costs -- surely (SURELY!) they are taking a hard look at childbirth in the U.S.

According to a 2008 report from the think tank Childbirth Connections, pregnancy is the most expensive condition for private insurers and Medicaid.

A recent article in the LA Times business (!) section puts together numbers that insurance companies and some doctors are starting to look at, as the former attempts to lower its costs and the latter attempts to improve outcomes.

Ahh, but what a thorny issue for a president to become involved in!

First, the surprises:

Childbirth is the No. 1 reason for hospital admission in the U.S.

Childbirth accounts for $79 billion in hospital charges alone of the nation's $2.4 trillion annual healthcare expenditures.

Cesarean sections are the most common surgery in the U.S.

Though one-third of all U.S. births are c-sections, rates among hospitals have mind-boggling variation. Among California hospitals, the c-section rate can be anywhere from 16 percent to 62 percent.

All those surgeries cost a fortune -- at an average of $4,500 for a c-section, that's twice as much as a vaginal birth in the hospital. For the privately insured, that number reaches an average of $13,000 for uncomplicated sections.

All these c-sections haven't improved outcomes. In fact, maternal deaths have risen since 2002.

Also, 48 percent of newborns admitted to neonatal intensive care units were from scheduled deliveries -- sections or inductions -- many of them before 39 weeks.

Miscalculated dates for inductions intended for 39 weeks gestation are also sending a growing number of newborns to the NICU until they can breathe on their own.

From the LA Times:

"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."

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Photo: LA Times

Did Catholic Church Push This Woman To Abort?

JeanneSager — Fri, 27 Feb 2009 21:28:00 GMT

The Catholic Church may well be the strongest advocates of the pro-life movement in the world, but a Canadian woman says doctors at a Catholic hospital pressured her to abort her baby.

On the face of it, the charges sound outrageous, even to someone who is pro-choice, but like most of these stories there's always a back story.

What mother Nikki Cooke refers to as a "eugenic abortion," was actually a suggested early induction of a baby carrying Trisomy 18, a a chromosomal defect that claims ninety percent of children by their first birthday. Many don't survive to even be born, which happened to the Cookes - the baby's heart stopped beating a week before Nikki was due to give birth.

The doctors had explained the slim chance that the Cookes' baby would be born alive and that there was nothing they can do. At one point, Cooke says she was told to terminate. One paragraph later, she's quoted saying they were "pressured to have an early induction." Which is it? Because inducing labor on a baby is not the same as an abortion. My daughter was induced, and she's very much alive.

Here's where some of the Cookes' claims could hold weight: Nikki says she was told IF her baby was born alive, the hospital would not resuscitate the baby. If that's true, the doctors in this case may have been legally protected, but ethically, that's absurd. How does a doctor allow a living, breathing child to go into respiratory failure and refuse to respond? Even if the child has a chromosomal difference, it's their obligation to make every attempt to keep that child breathing and the heart beating; at least until it is clear that there is simply no hope.

With Trisomy 18, there is little hope, it's true. But once a child is alive, that ten percent chance of survival is nothing to sneeze at.

The hospital, by the way, denies they would not treat a living baby. From the National Post:

"What is key for them is that labour is not induced until at least 23 weeks, when the fetus has reached viability, so if the baby is born alive everything possible could be done to save it. And if the diagnosis was wrong, the child would still have a chance."

It's also important to get back to the initial findings by the doctors - they didn't see the Cookes' baby surviving. They didn't see this baby being born alive, and they were advising a mother that it would be better to get her pregnancy over with sooner rather than continuing to carry around a baby who would not survive. Essentially, there was no hope. It comes to a point, the priest in the National Post article points out, where the safety and health (including emotional) of the mother has to come first.

According to the hospital guidelines in this case: "Medical treatment is permitted to prevent or cure a grave illness in a pregnant woman that cannot be deferred until the unborn child is viable even though the pregnancy may be endangered ... even though they will result in the foreseen but unintended death of the unborn child."

What's disturbing are the attempts by the pro-life movement to use this story as evidence that a mother is being wronged by a doctor making the determination that a fetus is not viable. It's sad for parents when this happens, but faith can't trump science. Sometimes, babies just won't make it. And it's important for parents to face that - as painful as it might be.

These are the same arguments used against women who opt for a D&C after a miscarriage, when the heart has stopped beating, and they are walking around with a non-viable fetus inside of them. They're branded murderers by some in the pro-life movement for what is, essentially, an abortive procedure - even though there is nothing there, there is no life in that tiny body.

You can't kill someone who isn't alive. You also can't call an inducement an abortion simply because the baby will not survive its chromosomal defects.

What do you think? Do you think the hospital was wrong here, or is this blown out of proportion?

Image: National Post

Woman Induces to Beat Health-Insurance Cancellation Date, Fails

Miriam Axel-Lute — Sat, 20 Dec 2008 21:40:00 GMT

It's a story painful in every way: Starla Darling was only days from her due date when she heard from a fellow Archway employee that the company was going bankrupt, they were being laid off, and their health insurance was being canceled in two days.

She panicked, ran to her midwives, had them induce labor, and ended up with an emergency c-section. She had been planning a water birth and natural labor. (Granted, there's no guarantee she would have had one anyway, but induction does increase the likelihood of c-section dramatically.)

The worst part? Insurance didn't cover it anyway and newly laid-off Darling has an $18,000 medical bill. She would have been better off to wait. But there was no way for her to know that and no one can blame her for taking what she thought was the cautious route.

It seems Archway was behind on its premiums and apparently the insurer has been denying a bunch of claims from that week, before the employees were told their coverage was ended. Frankly, at the least, someone ought to be responsible for making sure that claims made while employees still believed they had coverage are paid. After all, they had paid their share of the premiums. In fact, it's really Archway's fault more than the insurer, though I would hold Blue Cross Blue Sheild responsible too. That's just not OK.

I'm afraid we're only going to be seeing more of this stuff.

More by this author:

Pre-Term Elective C-Sections Are Dangerous: So Why Insure Them?

Miriam Axel-Lute — Fri, 19 Dec 2008 15:00:00 GMT

Michael McGuire is CEO of UnitedHealth, a health-insurance provider in New Jersey. In an op-ed in the Trenton Times recently he talked intelligently about the health dangers of elective pre-term c-sections.

The evidence keeps mounting—prematurity, even by a few weeks, means higher rates of breathing problems, cerebral palsy, NICU stays, etc. When the baby's not ready to come out, it's not ready, folks.

McGuire makes the impressive assertion that when he explained this carefully to a "pilot group" of physicians and hospitals and they stopped scheduling c-sections before 39 weeks, there was a 46 percent drop in NICU stays. Those are results to write home about. As he writes, "That's almost half the number of newborns with potential health problems, almost half the number of distraught parents, al most half the number of potential tragedies. The cost savings to these hospitals, the parents and the health-care system is enormous."

He notes carefully, as do I, that sometimes a pre-term c-section is medically necessary for health of mother and/or baby. Obviously, that is not what I'm talking about. But I would include c-sections that are planned for medical reasons,* but where there is no medical reason not to carry the baby to term. I think those are far, far more common than the over-hyped "too posh to push" phenomenon.

So here's what I want to know: If it's documented to be such a health risk, why don't McGuire and his colleagues just stop paying for c-sections that are unnecessarily scheduled at an unsafe time?

Insurers already go out of their way to not cover things they claim are optional (including some that are emphatically not), not to mention dangerous. Usually I question their judgment, but the evidence is pretty compelling on this one.

I'm all for educating docs, but it seems to me the insurers could stop this practice cold with their purse strings.

Photo by César Rincón.

*(Of course, many of those "medical reasons," like a previous c-sections or breech presentations, don't actually require a c-section, but that's a separate post.)

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They Say: Even Late Preemies at Higher Risk

Kate Tuttle — Mon, 15 Dec 2008 18:02:00 GMT

While it's long been known that premature babies face a much higher incidence of cerebral palsy and other medical problems, most of the infants thought to be at risk were those born before 34 weeks -- the tiny babies, notably premature, whose entire bodies can fit into the palm of their father's hands. But new research suggests that even bigger, healthier-seeming babies, when born before term, are much more likely to fall victim to the health problems of prematurity. And at a time when more and more women are giving birth early due to inductions or scheduled C-sections, that risk needs to be better communicated, according to the doctors who authored the study.

The study, which examined the circumstances of more than 140,000 babies born at 30 weeks or later, concluded that babies born from 34 to 36 weeks' gestation, although often appearing as big and healthy as full-term newborns, were three times more likely to have cerebral palsy than babies born at 37 weeks, and up to 25% more likely to face mental retardation and other developmental delays. Because the babies in the study have not yet entered elementary school, the authors point out, it's too early to know whether other learning-based problems will be detected.

While overall rates of prematurity are fairly steady, the number of babies born from 34-36 weeks is growing, and currently represents one in 11 births in the US. The study did not look into the reasons for the late preterm births, and some surely were medically indicated (pre-eclampsia, for instance, pretty much demands that a baby be born early, to save both lives).According to the study's authors, however, some of those "late preterm" births were due to early inductions or C-sections that were not medically necessary (remember that the next time a Hollywood starlet says she's due "sometime in the fall" and has a six-pounder).

Pre-term Elective C-Sections Are Dangerous: So Why Insure Them?

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They Say: Even Late Preemies at Higher Risk