Why does the most expensive health care system on the planet do such a poor job protecting the lives of pregnant women? More important, what can be done about it?
The United States continues to lead the world in health care spending yet it has the highest maternal death rate among wealthy nations. Researchers have found that maternal mortality in the United States increased by 26.6% from 2000 to 2014 even though it declined in almost every other developed country. Even more concerning is that an estimated 60% of pregnancy-related deaths in the United States are preventable, according to the Centers for Disease Control and Prevention (CDC).
Ask OB/GYN physicians about these troubling figures, and they’ll point to a variety of contributing factors: American women are having babies later in life, increasing the chances of complications. In large cities like New York and San Francisco, for example, the average age for first-time mothers is now over 30. Higher rates of maternal obesity, substance abuse, and poverty also contribute to complications before, during, and after childbirth.
But these demographic shifts do not explain the full magnitude of the problem. After all, the two most common causes of maternal death as a result of childbirth are (1) unrecognized bleeding (or postpartum hemorrhage) and (2) extreme blood-pressure elevation before or following delivery.
The medical community has proposed a variety of solutions to address these problems, including better training for doctors, more labor and delivery (L&D) nurses, and longer inpatient stays to allow for additional monitoring.
Indeed, all of these approaches would help. But let’s take a big step backward and ask ourselves: If we could redesign U.S. health care’s current approach to labor and delivery, would we choose the current model or something different?
I know we can do better.
Looking closer at the traditional model of child delivery
The doctor-patient bond is an incredibly important part of the mother’s pregnancy. For physicians, detailed knowledge of each patient helps with assessing the health of both mother and baby, and monitoring fetal development. Patients value this level of familiarity and, because of it, trust their doctor’s recommendations.
However, once labor commences and the patient arrives at the L&D suite, doctor-patient familiarity becomes far less important than doctor-patient proximity. And contrary to what most pregnant women believe, their doctor is likely to be far away should an unexpected medical crisis arise.
Most OB/GYN physicians spend their days at the office and their nights at home—not at the hospital where most American mothers have their babies. The physician’s absence usually isn’t a problem. After all, statistically, most childbirths go well. But when problems do arise, time is of the essence.
A better approach to keeping mothers safe
Obviously, OB/GYN physicians can’t be in their office and the hospital at the same time. And since there’s no way to know when patients will go into labor, these doctors typically have to scramble when one of their patients begins to experience contractions.
The solution for this dilemma isn’t new. It already exists in a small number of U.S. hospitals and is associated with fewer maternal deaths.
The approach relies on hospital-based obstetricians who spend an entire eight- to 12-hour shift in the L&D suite. This way, there’s always a skilled and experienced OB/GYN doctor available to all laboring mothers around the clock.
From the very second of the mother’s arrival, these “obstetrical (or OB/GYN) hospitalists” are present and able to monitor mothers for bleeding, assess blood pressure before and after delivery, and intervene immediately should an unexpected problem arise.
One state’s proof of concept
Nationwide, the overall maternal death rate is 23.8 per 100,000 live births. Among individual states, the rate is lowest in California (4.0 per 100,000).
Many factors contribute to California’s superior results. Some are socioeconomic and demographic, but two are unique to the state’s health care system.
First, 24% of the California’s community hospitals use OB/GYN hospitalists. By contrast only 10% of all U.S. hospitals that provide obstetrical care currently employ this approach.
Second, California leads the nation with 21.4 million individuals enrolled in HMO plans, more than triple the next-highest state. These health plans are more often connected to large multispecialty medical groups, many of which employ the hospitalist model to maximize quality outcomes. The combination of large, integrated medical centers and more community-based obstetrical hospitalists resulted in a 55% reduction in maternal deaths in California from 2006 to 2013—a period during which the rest of the nation saw a significant increase.
There’s yet another benefit to the multispecialty medical group model. Since labor can happen 365 days a year, many OB/GYN physicians currently schedule elective Caesarian sections before the weekend or ahead of their planned vacations, rather than taking a chance on labor commencing while they’re away. This helps explain why the number of scheduled C-sections performed in the United States is more than double the World Health Organization’s recommended rate of 10-15%. Unfortunately for moms, having an elected C-section can significantly increase the chances of death compared to non-operative delivery. When the OB/GYN hospitalist approach is used in large medical groups, the financial incentives for scheduling an elective C-section disappear and the rate of unnecessary interventions decreases.
Challenges scaling the hospitalist model
Despite California’s success with OB/GYN hospitalists, it will be difficult to replicate and expand this model nationwide. There’s an economic reason for that: Most of the nation’s obstetrical hospitalists are hired to augment (not replace) office-based OB/GYNs.
This redundancy occurs because most community physicians won’t direct their pregnant patients to a hospital unless they’re able to bill for the delivery. And since most insurance companies won’t pay two different doctors for a single delivery, hospital administrators don’t want to shoulder the added expense, even if it improves outcomes.
Although we can’t be sure how many lives the “omnipresent obstetrician” approach would save, we do know this: The current data suggest that this model, if implemented everywhere, would lower maternal mortality significantly, as in California.
Making it easier for patients to choose the safest hospitals
If we’re going to do everything we can to protect the lives of mothers, there’s one more major problem to address.
As hard as it is to believe, U.S. hospitals are not currently required to provide data on their approaches, outcomes or complication rates to any regulatory or accrediting body.
We don’t know for sure why it’s this way, but it seems American medical culture is more concerned with protecting the reputation of underperforming facilities than it is with protecting the safety of mothers.
A related media story shines a light on the problem inherent in today’s “voluntary” hospital reporting: It took a month-long investigation by The New York Times to get the North Carolina Children’s Hospital to release even limited data on cardiac surgery outcomes. The numbers tell a frightening story.
Not only are the program’s results near the bottom of the nation, but “the death rate at the North Carolina hospital was especially high among children with the most complex heart conditions—nearly 50%, the data shows.”
Given the huge variation in maternal mortality by state, we can be sure the same types of issues exist among hospitals with L&Ds. We just can’t determine which ones are the most problematic.
Outcome data would not only help families make smarter health care decisions, but the information would also lead to improvements in care. Unfortunately, hospital reporting across the U.S. remains voluntary and the data, itself, rarely is used to drive improvements. As a consequence, half of all states still don’t formally review the causes of maternal death to find out which fatalities were preventable or to how to reduce future deaths.
Patients trust their doctors and, as a result, believe the current OB/GYN model is best. They assume the care they receive is excellent, but objectively, this isn’t the case.
Identifying the facilities with the greatest problems would help mothers make the best choice for themselves and their unborn child. It also would drive improvements in clinical performance.
But if our nation is truly committed to becoming a world leader in preventing maternal deaths, we will need to change the underlying model to ensure an obstetrician is continually available. Of course, getting physicians to agree won’t be easy, but it will save lives.
Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.
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