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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.

Pregnancy Pathway, Preconditions

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Please refer to February 5 entry for complete graphic. Today we turn to the question of preconditions to pregnancy and how they might affect maternal and offspring health.

Preconditions

Preconditions

Pre-existing factors that can influence health outcomes include genetic factors (family risk for heart disease, for example), environmental factors (living in a building with mold, for example), and behavior (eating well and exercising, for example). In each category, factors will contribute to the health of the mother and eventually to offspring health.

It is important to understand what major genetic factors may affect your offspring and whether the environment or behavior can help offset negative factors. For example, there may be a history of preeclampsia during pregnancy in your family, but vigorous aerobic exercise in the six months prior to pregnancy provides a high degree of protection from this risk. Preeclampsia puts both mother and offspring at risk for complications.

Other genetic factors that may be of consequence include autoimmune disorders, allergies, and metabolic syndromes. For example, so-called “thrifty genes” may predispose you to a high weight gain in pregnancy. But, you may be able to offset health problems associated with this by staying active and eating well.