health care reform

The 51% Factor: Pregnancy, Power & Health

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In the U.S. and most of the devel­oped world, approx­i­mate­ly 51% of the pop­u­la­tion is female. Most females give birth at some point in their lives, although, in any year, only about 2% of the pop­u­la­tion gives birth.

No one liv­ing on earth got here any oth­er way than ges­ta­tion, so there ought to be some pow­er attached to being part of that 51%. His­tor­i­cal­ly, it might be said that the pow­er has been mere­ly for survival…the good breed­ers sur­vived long enough to pro­duce heirs and those who lived on knew where the roots and fruit grew.

Only women can make more peo­ple with their bod­ies.

Here are some things to con­sid­er:

  • Women make peo­ple
  • Women’s health and fit­ness before preg­nan­cy affects whether the preg­nan­cy is healthy
  • Women’s health and fit­ness dur­ing preg­nan­cy affects her life­time health and that of her off­spring
  • Mater­nal sur­vival is impor­tant to off­spring well-being
  • Mater­nal health and fit­ness affects mater­nal adap­ta­tion and there­by off­spring well-being

Thus, is it not a san­guine notion that the health and sur­vival of women is crit­i­cal to the health of every­one? After all, the health of nations is asso­ci­at­ed with this slight major­i­ty of females, and the wealth of nations is asso­ci­at­ed with its health.

The good news is that peo­ple work­ing from this under­stand­ing are mak­ing some head­way around the globe. Recent­ly, the World Health Orga­ni­za­tion not­ed that mater­nal death among preg­nant and birthing women world-wide has been dra­mat­i­cal­ly reduced from the 1980’s to recent­ly. This is very good news!

Here is the inter­est­ing foot­note:  Mater­nal death in the U.S. has risen 42% in the same peri­od. While the absolute num­bers remain small, this is a dis­turb­ing pic­ture. What could be caus­ing this?

Time will tell if we can fig­ure it out and fix it. I ven­ture to sug­gest some direc­tions for con­sid­er­a­tion:

  • The ele­vat­ed cesare­an birth rate with its sequel­lae of car­dio­vas­cu­lar and immune sys­tem dis­or­ders
  • Obe­si­ty
  • Meta­bol­ic syn­dromes
  • Dia­betes
  • Heart dis­ease

Why am I hope­ful, then? I see among our cur­rent edu­cat­ed gen­er­a­tion of new moms and moms-to-be a will­ing­ness to exert their influ­ence – as breed­ers – over the health care scene. They want less tech­no­log­i­cal birth. They want sup­port. They want more infor­ma­tion. They want to be healthy. These are won­der­ful things. I salute these young women…they also make my job eas­i­er in the process.

In addi­tion, I see among young health care prac­ti­tion­ers an under­stand­ing of the val­ue of these things. Among prac­ti­tion­ers work­ing in pub­lic health clin­ics there is a sense of des­per­a­tion on the one hand that the poor and indi­gent have no capac­i­ty or will to take care of them­selves. On the oth­er hand, the first step is always edu­ca­tion and there are a lot of peo­ple work­ing on this issue.

Which brings me to the clos­ing point:  How do we bring more resources and intel­li­gence to help­ing women be healthy, pre­pare for preg­nan­cy, have healthy babies, reduce preg­nan­cy com­pli­ca­tions, and improve infant and mater­nal death rates? I, for one, will keep blog­ging on this issue. You, I hope, will vote for peo­ple who under­stand this issue. The polit­i­cal pow­er and will is in our hands.

51% of us are women…some day 51% of us can set pri­or­i­ties

Rant: Health Care Reform/Pregnancy

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Since Health Care Reform is a hot top­ic, let’s look at it from the per­spec­tive of preg­nan­cy and birth.

What revi­sions would most ben­e­fit preg­nant women, their off­spring, fam­i­lies and com­mu­ni­ties?

1. Reward healthy behav­iors. A sys­tem that pro­vides reduced pre­mi­ums for health care for women who exer­cise, eat well, do not smoke and are in a nor­mal weight range is evi­dence-based.

Yes! We could pro­vide finan­cial incen­tives for being healthy dur­ing preg­nan­cy. Why? Healthy moms have healthy babies; healthy babies cost the pay­er less mon­ey.

2. Review best prac­tices. Is a 40 or 50% cesare­an rate the best prac­tice?  Accom­pa­ny­ing the rise in cesare­an births is grow­ing infor­ma­tion that babies born by cesare­an are at increased risk for a num­ber of immune dis­or­ders. But the busi­ness mod­el of med­i­cine rewards cesare­an because it both pays the provider more and is defen­sive med­ical prac­tice.

Fetal mon­i­tor­ing to deter­mine if a cesare­an may be nec­es­sary, is wrong 3/4 of the time. In an effort to change this, guide­lines are chang­ing for the use of mon­i­tors dur­ing labor. What is the evi­dence that this change of prac­tice is ben­e­fi­cial? Will it lead to more or less mon­i­tor­ing, which may itself be an inter­ven­tion that can dis­rupt nor­mal labor?

3. Change the busi­ness mod­el for health care. When we make finan­cial incen­tives for care providers, base them on best prac­tice, not on enrich­ing the mid­dle man. Cur­rent­ly the pay­ers (insur­ance com­pa­nies) are mid­dle men, mak­ing mon­ey (i.e., con­duct­ing busi­ness) by charg­ing fees. They ration pay­ments for ser­vices in order to pay their own salaries and over­head. They do not actu­al­ly do any­thing pro­duc­tive. This is why sin­gle pay­er, gov­ern­ment, and health care coop options have been pro­posed. They elim­i­nate most of the cum­ber­some mid­dle lay­er.

Why does insur­ance pay for cesare­ans? Well, they will do it once. After all, the care providers have to prac­tice defen­sive med­i­cine. But, once you have a cesare­an, you become a risk for the insur­ance com­pa­ny (they know what the research says about cesare­ans and off­spring health prob­lems) and may be denied insur­ance. They can no longer afford you.

Because care providers are paid fee for ser­vice and must prac­tice defen­sive med­i­cine, preg­nan­cy and birth have become increas­ing­ly bur­dened with inter­ven­ing pro­ce­dures that do not nec­es­sar­i­ly pro­mote a healthy preg­nan­cy or birth process. How is this play­ing out? Increas­ing­ly, we see women giv­ing birth in what they per­ceive as a more sup­port­ive and health-induc­ing set­ting:  their own homes. Think of it this way:  many women now believe that it is safer to stay home than go to a hos­pi­tal to give birth.

Unless health care becomes about best prac­tices and healthy out­comes — not price, size, and get­ting paid for pass­ing mon­ey back and forth — the U.S. will con­tin­ue to have some of the worst maternal/infant out­comes in the devel­oped world.