ICAN of Somerset County, NJ

UPDATE on the case where NJ DYFS removed child from a mom who refused a cesarean

I spoke with "V" the other day and the appellate court reached a decision against her.  They decided to confirm that abuse and neglect had been committed against the child over V's refusal of a cesarean during labor.  The following document was released by the NJ courts  and should dispel any rumors about the actuality of this case. 

http://www.judiciary.state.nj.us/opinions/a4627-06.pdf

The story is a bit mixed in the report above.  They wanted her to sign a blanket consent form upon arrival at the hospital for a cesarean. She refused and they got mad stressing the importance of their ability to do a cesarean quickly if necessary.   Later, the baby was "showing signs of distress."  So what did they do?  They tried even harder to push the potential need for a cesarean.

The fact is that cesareans are seldom so emergent that there is no time for consent.  St Barnabas has a nearly 50% cesarean rate.  Why couldn't they do something else to relieve the alleged "stress" on the baby before yelling at this women about a cesarean?  Why not try repositioning her?  They were upset about how V acted in labor.  That's why it's called labor!  It doesn't tickle!  The report claims the nurses were trying to restrain her.  V claims they bruised her because they were so rough.  Baby was born at 35 weeks and was in good health for being slightly premature and doesn't seem to have suffered distress during labor (of course "distress" in labor is NOT easily defined, especially when diagnosed by looking at fetal monitors). 

As far as the custodial issue goes, DYFS psychiatrists don't believe that V is capable of caring for a child.  They stressed to her that it is a 24 hour job.  They don't think she could feed or diaper a baby.  They are concerned because she has had psychiatric problems in the past. 

I'm not trying to preach a belief that V would be mother of the year.  But the custodial issue only came up because she delivered at St Barnabas and they wanted the freedom to do a c-section at will.  DYFS always seems to be willing to work with illegal drug addicted mothers and return their children after a working with them.  I personally know of a case where the mom went back on drugs and moved.  DYFS and CPS of the particular state haven't acted very quickly trying to remove that child from the situation. 

A judge told V in one of her hearings that he felt she would be too argumentative and that would wind up hurting her child.  For instance, she would argue with teachers and receptionists at the dentist office.  Well, I'm sure all NJ teachers and receptionists are breathing a sigh of relief since parents so seldom aruge with them. 

They call V paranoid and claim there is something wrong with her.  I think I'd be paranoid too if someone took my baby away from me.  Physically and emotionally, that has to take an incredible toll on a woman who is not expecting that.  V wishes the doctors had told they didn't believe she was fit to be a mother so she could have made arrangements to have her child cared for by someone she knew.  V is being told that doctors can decide which people are fit to be parents. 

This is a tough case.  It was all instigated over a cesarean that was not ultimately needed.  How much time and money are being invested into keeping V's child away from her rather than trying to work with her and help her learn whatever parenting skills they feel she needs?

Lawsuit... over a cesarean?!

THURSDAY, JULY 09, 2009 3:30:00 PM
Michigan Supreme Court: Family can sue for loss of services BY CHRIS RIZO Michigan Supreme Court building LANSING, Mich. (Legal Newsline)-A dead mother's family can sue for damages for loss of household services, a divided Michigan state Supreme Court ruled this week. The court's majority said Laurie Ann Greene's family can sue Mercy Memorial Hospital in Monroe, Mich., for $1.4 million for a loss of household services. The family alleges Greene died because she bled to death from the site of a Cesarean section. They allege medical malpractice in the case. Last year, the state appeals court ruled that household services such as caring for children are not subject to caps on medical malpractice damages related to pain and suffering. The hospital appealed the decision to the state Supreme Court, arguing that the loss of household service is noneconomic and subject to a damage cap. In a 4-3 vote, the high court's justices said they would not hear the hospital's appeal. From Legal Newsline: Reach staff reporter Chris Rizo at chrisrizo@legalnewsline.com. Filed Under: State Supreme Courts http://www.legalnewsline.com/news/221916-michigan-supreme-court-family-can-sue-for-loss-of-services

NJ midwifery laws in legislation to recognize midwifery as independent practicioners

http://www.nj.gov/oag/ca/proposal/bmepro_060109.htm

Please go to this website and submit your comments in favor of this legislation by July 31, 2009.  NJ needs more midwives and we should recognize them as an independent practice without the need for a doctor to dictate how they can practice:

NEW JERSEY REGISTER
VOLUME 41, ISSUE 11
ISSUE DATE: JUNE 1, 2009
RULE PROPOSALS
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF MEDICAL EXAMINERS

Proposed Amendments: N.J.A.C. 13:35-2A.2, 2A.5 and 2A.6

Certified Midwives
Definitions; Independent Practice; Affiliated Physicians; Clinical Guidelines

Summaries of 4 large VBAC studies

Great info on VBAC from ICAN's Advocacy Director!

Summary of the Four Largest and Most Recent VBAC and Elective Repeat Cesarean Studies
by Gretchen Humphries

The purpose of this article is to provide a simple summary of the four largest and most recent studies done on vaginal birth after cesarean (VBAC) and elective repeat cesarean (ERC). Because complications associated with any form of birth are rare events, large numbers of births must be studied to gain an accurate measure of those complications. It is important to not rely on interpretation of opinion when making a decision about VBAC, but rather to assess the available data and make an informed decision based on fact, not emotion. While I have very strong opinions about the inherent flaws, and even dangers represented by the medical model of obstetrical care, the fact is that most women plan births within that system. Therefore, it is appropriate to look at the information provided by that system.

There are serious flaws in all of these studies; flaws that may over-estimate the risks specifically associated with VBAC. Nevertheless, the results of these studies still support VBAC as a safe and reasonable choice for most women. Uterine rupture is the one obstetrical complication that is most popularly associated with VBAC trials of labor (TOL) and as such, is often used to discourage VBAC TOLs, in spite of its rarity. While these studies do not accurately assess the risk of uterine rupture in a completely unmedicated VBAC (there are no published studies that do so), they probably do accurately assess the risk involved in a typical hospital VBAC as managed by an obstetrician.

Study 1

"Risk of Uterine Rupture During Labor Among Women With a Prior Cesarean Delivery" Lyndon-Rochelle M, Holt VL, Easterling TR, Martin DP NEJM Vol. 345, 3-8 July 5, 2001.

20,095 women with 1 prior cesarean section comprised the study group. They each gave birth to a live, single infant between 1987 and 1996.

Uterine rupture:

Elective repeat cesarean (ERC) with no labor: 0.16% (11 of 6980)
Spontaneous onset of Labor (SOOL): 0.52% (56 of 10,789)
Induction of Labor without Prostaglandin: 0.77% (15 of 1960)
Induction of Labor with Prostaglandin: 2.45% (9 of 366)
The overall risk of uterine rupture in all TOL groups was 0.6% (80 of 13115)
There was no information given about augmentation of labor in any of the groups that labored.

Complications such as diabetes mellitus, chronic hypertension, pre-eclampsia, breech presentation, genital herpes or placenta previa were not associated with a higher risk of uterine rupture. Likewise, prior lower vertical incision was not associated with an increased risk of uterine rupture.

Fetal Deaths:

There were 5 fetal deaths in the women that had uterine ruptures (91 total ruptures). The authors didn't report which specific groups were involved. There were 100 fetal deaths in the women that did not have uterine ruptures (20,004 total).

If all of the uterine rupture associated deaths occurred in the groups of women that labored, then the risk of the baby dying as a result of a uterine rupture associated with TOL is 0.04% (5 of 13115), over 10 times less than the risk of the baby dying for any other reason (0.5% or 100 of 20,004).

Conclusion from the study:
"At present, the data suggest that induction of labor increases the risk of uterine rupture among women with one prior cesarean delivery and that labor induced with use of a prostaglandin confers a greater relative risk. The overall effect of induction of labor with prostaglandins on uterine rupture is still unclear and may vary according to the preparation used, the regimen, and the degree of cervical readiness for induction."

Study 2

"Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989 to 1999" Mozerkewich, EL and Hutton EK. Am J Obstet Gynecol Vol. 183, 1187-1197, Nov. 2000

The authors of this study searched MEDLINE and EMBASE databases for all English language published reports, between 1989 and 1999, on VBAC, TOL, trial of scar (TOS) and uterine rupture. They selected a total of 15 studies that were of a quality and make-up to be appropriate for meta-analysis - they pooled the data from each individual study together and re-analysed the data as a whole, as appropriate for each item they were analyzing.

They analyzed for uterine rupture, maternal mortality, fetal or neonatal mortality, low APGAR score, maternal transfusion and hysterectomy. Uterine rupture was defined as symptomatic, requiring surgical repair or involving extrusion of fetal parts. All women who chose ERC were eligible for a TOL and opted for surgery instead.

28,813 women attempted VBAC with 20,746 achieving a vaginal birth (72.3%).

Uterine Rupture:

TOL group: uterine rupture rate was 0.4% (4 of 1000)
ERC group: uterine rupture rate of 0.2% (2 of 1000)

Maternal Deaths and Complications:
There were 3 maternal deaths among 27,504 women in the TOL group. All 3 women were undergoing a repeat cesarean after TOL. There were no maternal deaths among 17,740 women undergoing an ERC. The difference between the 2 groups was not statistically significant.

Maternal febrile morbidity (fever) was less frequent among women in the TOL group. This was significant across all the studies that looked at this complication.

Need for a transfusion was significantly less among women in the TOL group. This was significant across all the studies that looked at this complication.

Need for a hysterectomy was significantly less in the TOL group in all but 1 study, which found no difference between TOL and ERC groups.

Fetal Deaths and Complications:

Deaths due to intrauterine death before labor, lethal birth defects and prematurity were excluded.

TOL births: 0.2% (38 of 19,842).
ERC births: 0.1% (10 of 13,292).
There was no way to determine the actual cause of any of these deaths, so no conclusions can be drawn as to the impact uterine rupture may or may not have had, as opposed to other obstetrical conditions and interventions.

5-minute APGAR: 7 was more common in the TOL group but this was statistically significant in only 2 of 7 studies that were used for this comparison.

Facts of note:

Between 693 and 3332 women would need to undergo ERC to prevent a single fetal or neonatal death attributable to TOL.
Between 374 and 809 women would need to undergo ERC to prevent a single case of uterine rupture.

Conclusion from the study:
"Our findings suggest that small increases in the uterine rupture rate and in fetal and neonatal mortality rates may result from a trial of labor with respect to elective repeat cesarean delivery. These increases may be counterbalanced by reductions in maternal morbidity with a trial of labor, including febrile morbidity, transfusion, and hysterectomy. Either a trial of labor or elective repeat cesarean delivery may be a reasonable option for women with at least one previous cesarean delivery."

Study 3

"Vaginal Birth After Cesarean and Uterine Rupture Rates in California" Gregory KD, Korst, LM, Cane P, Platt, LD, Kahn, K. Obstet & Gynecol Vol.94, 985-989, Dec. 1999

This study looked at the hospital discharge data for 536,785 women who gave birth in California in the year 1995.

The overall cesarean rate that year was 20.8% (111,374 of 536,785)
Women who had previous cesarean(s) were 12.5% (66,856 of 536,785) of the study group.
ERC: 40.3% (26,943 of 66,856)
TOL: 59.7% (39,913 of 66,856).
Successful VBAC: 61.4% (24,024 of 66,856)
VBAC in all women with previous cesarean: 35.9%
A hospital that had at least a 60% TOL rate in women with previous cesarean was defined as having a "high attempted VBAC rate". Women who gave birth in a high VBAC rate hospital (286,007 - includes women that did not have a previous cesarean) had lower cesarean rates (18.5%), higher VBAC rates (65.0%) and higher rupture rates (0.088%).
Women that gave birth in a low rate hospital (248,930) had higher cesarean rates (23.3%), lower VBAC rates (55.6%) and lower uterine rupture rates (0.056%).

Uterine Rupture:
The study design did not allow for objective definition of "uterine rupture".

All deliveries: uterine rupture rate was 0.07% (392 of 536,785)
All women with prior cesarean: uterine rupture rate was 0.43% (288 of 66,856)
ERC: uterine rupture rate was 0.28% (79 of 22,760)
TOL: uterine rupture rate was 0.53% (209 of 39,096)
Failed TOL: uterine rupture rate was 1.15% (174 of 15,072)
VBAC: uterine rupture rate was 0.15% (35 of 24,024)
Uterine rupture was 1.9 times more likely if TOL was attempted but only 34% of the uterine ruptures in women with a history of cesarean could be attributed to TOL.

Maternal age was found to be a significant predictor of uterine rupture but the authors were not able to associate this with useful data such as number of prior cesareans or number of previous pregnancies to determine if age was independently important or not.

The data did not include any information on fetal outcome so there was no way to estimate the risk of injury due to uterine rupture.

Conclusion from the study:
".in this ethnically diverse, population-based study, the uterine rupture rate for women attempting a trial of labor was 0.53%. This corroborates the relative safety of VBAC, with respect to uterine rupture, that has been demonstrated in smaller, institutionally-based samples."

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Study 4 "Delivery After Previous Cesarean: A Risk Evaluation" Rageth JC, Juzi C, Grossenbacher, H. Obstet and Gynecol 93: 332-337, March, 1999.

The data was collected from questionnaires that were used to collect information for quality-control purposes, in 40% of the deliveries in Switzerland, from 1983 through 1996. All participants in the study had at least one previous birth to the birth recorded in this data set.

Women with a previous cesarean: 11.37% (29,046 out of 255,453).
TOL: 60.64% (17,613 of 29,046).
ERC: 39.36% (11,433 of 29,046).

Spontaneous onset of labor: 86.04% (15,154 of 17,613)
SOOL vaginal births: 75.06% (11,374 out of 15,154)
Induction TOL: 13.9% (2459 out of 17,613)
Induction vaginal births: 65.56% (1612 out of 2459)

Uterine Rupture:

ERC: uterine rupture rate was 0.19%. (22 out of 11,433)
TOL: uterine rupture rate was 0.39% (70 out of 17,613)
Induced TOL: uterine rupture rate was 0.65%
This difference was found to be statistically significant.

41.43% (29 of 70) of the TOL uterine ruptures were augmented labors.
35.80% of the TOL with no ruptures were augmented.
This difference was not found to be statistically significant.

Maternal Complications:

Women in the TOL group were statistically significantly less likely to need a hysterectomy than women in the ERC group (0.16% vs. 0.45%)
Women in the TOL group were statistically significantly less likely to suffer from fever (1.5% vs. 2.29%)
Women in the TOL group were statistically significantly less likely to have thromboembolic complications (0.22% vs. 0.43%)

Women with a prior cesarean were 1.87 times more likely to have a placental abruption during pregnancy and 1.49 times more likely during labor.

Fetal Deaths and Complications:

43 total fetal deaths (not associated with prematurity or birth defects).
ERC: 0.09% (10 of 11,433 or 0.09%)
TOL: 0.19% (33 of 17,613) This difference was slightly statistically significant.

TOL: risk of baby dying due to rupture was 0.03% (5 of 17,613)
ERC: risk of baby dying due to rupture is 0.009% (1of 11,433)

VBAC: babies transferred for further medical treatment was 5.08%.
Unsuccessful TOL: babies transferred for further medical treatment was 8.97%.
ERC: babies transferred for further medical treatment 8.30%.

Other findings:

Epidural anesthesia was associated with a higher risk of rupture but this might be associated with higher epidural use during induction, or other known risk factors.

Cephalopelvic disproportion (CPD) and macrosomia were not associated with higher rates of uterine rupture.

Conclusion from the Study:
"Our data show that a trial of labor after previous cesarean is safe and can be recommended in the majority of cases."

Closing Comments:

All of the studies were based on data collected off of summary paperwork (insurance billing, birth certificates, survey forms, other published studies), completed by many different individuals. Other studies have shown that the error rate in how particular medical events (such as uterine rupture or maternal hemorrhage) are recorded is quite high in this type of analysis. Unless the study authors review the actual medical chart of each individual patient, there is the very real probability that the data used in the study is inaccurate.

Only one of these studies (number 4) made any attempt to determine if augmentation of labor had an effect on rupture rates. While they concluded that it did not, the method they used to draw that conclusion may not have had the statistical power to show significance.

Only one study (number 1) looked at only women with a history of 1 prior cesarean birth and no other births. Multiple cesareans and previous vaginal births are known to have an affect on a number of complications (e.g. uterine rupture rate, placenta previa rates).

There was no information available in any of the studies about specific characteristics of women in the induced labor groups - cervical readiness (Bishop's score) may be an important factor.

Only one study looked at epidural use (study 4) and concluded it was a risk factor for uterine rupture, but not one that could be proven to be independent of other risk factors. There was no analysis of the use of other drugs during labor, nor was there any analysis of how the women labored (for example, confined to bed with electronic fetal monitoring or with artificial rupture of membranes early in the course of the labor).

The fear that is most often played upon when a woman is being "informed" about the risks of VBAC is the death of her baby due to uterine rupture. It is obvious from all of these studies that the risk of this particular outcome is very low in the TOL groups. It is also obvious that ERC is not a guarantee that a rupture will not occur, nor is it a guarantee that a baby will not die. Hopefully this information will put all of the risks associated with VBAC vs. ERC in some perspective.

Once again, it bears mentioning that there are no published studies looking specifically at complication rates in completely unmedicated, "natural" VBACs vs. ERC or a medically managed VBAC. There are certainly no published studies looking at complication rates in out of hospital VBACs. Many people assume that complication rates in the "natural" VBAC would be lower than in any other birth - the fact that induction is a factor in uterine rupture and that epidural use might be, is at least supportive of this assumption. Until data on out of hospital VBACs is published, this must remain an assumption. Hopefully, such a study will be published in the near future.

Copyright © 2002 by Gretchen Humphries. All rights reserved. Used with permission.

Gretchen Humphries is the mother of twin boys, delivered via cesarean section in June, 1998 and of a daughter, born at home in January of 2001. She's also a part-time Doctor of Veterinary Medicine. Her own birth experiences have impassioned her to help other women find and have the births that they want and need.

http://www.storknet.com/cubbies/vbac/4studies.htm

Cesareans. Are They Risk Free??

A great piece written by an ICAN chapter leader!

Cesarean Sections
Are They Risk-Free?

In the United States, cesarean (si-‘zar-E-an) sections are one of the most common surgeries for women. With 31.8% of women delivering babies via cesarean, it is easy to assume the surgery is risk-free.  What women are often told after a cesarean is that a healthy baby was the most important outcome. However, the cesarean can sometimes be at a cost to the mother's emotional and physical well-being.

When a cesarean is necessary, it can be a lifesaving procedure for both mother and baby.  A cesarean section is major abdominal surgery used for the delivery of an infant through an incision in the mother’s abdomen and uterus. The incision may be made across the bottom of the abdomen above the pubic area (transverse) or in rare instances, in a line from the belly button to the pubic area (vertical).

There are specific times when a cesarean becomes truly necessary. A cesarean section is indicated in the following situations:

• Complete placenta previa at term
• Transverse lie at complete dilation
• Prolapsed cord
• Abrupted placenta
• Eclampsia or HELLP with failed labor induction
• Large uterine tumor that blocks the cervix at complete dilation (Most fibroids will move upwards as the cervix opens, moving out of baby’s path.)
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True absolute cephalopelvic disproportion or CPD (baby too large for pelvis) This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break).
• Initial outbreak of active herpes at the onset of labor
• Uterine rupture

Many reasons given for cesarean, especially prior to labor, can be questioned. This includes macrosomia (large baby), maternal age and parity, assisted reproductive technology, CPD, dystocia, failure to progress, breech, fetal distress or even prolonged second stage. Fetal positioning during labor and maternal positioning during second stage, most notably when women are in a semi-sitting position, causes most CPD diagnosed in current obstetrics. There are very few true indications for a cesarean section where the risks of surgery outweigh the risks of vaginal birth.

The risks of cesarean surgery are mental and physical affecting both mother and baby.  Psychological outcomes such as negative feelings, fear, guilt, anger and postpartum depression are common consequences of both emergent and elective cesarean sections.

A cesarean poses documented medical risks to the mother’s health. These risks include infection, blood loss and hemorrhage, hysterectomy, transfusions, bladder and bowel injury, incisional endometriosis, heart and lung complications, blood clots in the legs, anesthesia complications, and rehospitalization due to surgical complications. 

Scar tissue makes subsequent cesareans more difficult, increasing the risk of injury to other organs and the risk of chronic problems from adhesions. Potential chronic complications from adhesions include pelvic pain, bowel problems, and pain during intercourse.  The mortality rate is at least two to four times that of women with vaginal births.  One-half of women who undergo a cesarean section suffer complications.  

Each successive cesarean increases risks for future pregnancies.  The more cesareans a mother undergoes, the greater the risk of placenta previa, placenta accreta and placental abruption in subsequent pregnancies.  These complications can be life-threatening to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy.

A cesarean poses documented medical risks to the baby’s health, as well. Risks include respiratory distress syndrome (RDS), iatrogenic prematurity (surgery performed too early due to an error in determining due date),  persistent pulmonary hypertension (PPH), and surgery-related fetal injuries such as lacerations,  An elective cesarean section significantly increases the risk of premature birth and respiratory distress syndrome, both associated with multiple complications, intensive care and burdensome financial cost.   Additionally, cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding, and the establishment of family bonds.

The best approach for a mother to reduce her chances of a cesarean is to become educated.  Education can include attending birth education classes in and out of the hospital environment.  Additionally, mothers can research risks and benefits of routine and emergency procedures before they are faced with them.  When faced with any procedure, mothers are entitled to have informed consent outlining the short and long term effects on the mother, baby, and the labor process.  Are there other options to the procedure?

Another strategy for mothers is to choose a care provider and a birth facility wisely.  Cesarean rates are often influenced by non-medical factors. These include: individual care provider philosophy and training, convenience of doctor or patient, the patient’s socioeconomic status, peer pressure, fear of litigation, and financial gain.

When choosing a care provider, mothers benefit from interviewing more than one provider. Some interview questions are the following:  Do they have a set time limit for labor and second stage pushing?  What does the provider feel can interfere with the normal process of labor? Under what circumstances do they use medical interventions such as labor inductions?   Are post date pregnancies a problem?  It is helpful for the mother to educate herself ahead of time and determine if the answers are evidence -based.  As with care providers, it is important to tour more than one birth facility –note the differences, find out the cesarean rate, etc.

Additionally, research shows that labor support such as a doula reduces the need for a cesarean.  When selecting a doula, number of births, and experiences with normal, non-interventive birth are factors to consider.

In our society, educated consumers shop around for quality merchandise. First time parents spend time filling out baby shower registries to ensure they get just the right items.  Even more essential for families, is to take, at a minimum, the same amount of care to choose a care provider and birth facility.   Although there are no guarantees, the anticipated outcome of a pregnancy is a healthy baby.  However, the real goal to work towards is a physically and emotionally healthy mother and baby.  Pregnancy, labor, and birth are the critical beginnings that shape the essential mother/child bond for life.   

Editorial provided by Julie Herr, a Co-Leader of ICAN of St. Louis, a local chapter of the International Cesarean Awareness Network, Inc. This information has been reprinted with permission from the national headquarters of ICAN.
http://www.expectantmothersguide.com/library/stlouis/cesareansection.htm

The Maternity Crisis in Philadelphia and South Jersey...

       http://www.metrokids.com/july09/maternity0709.html

Body Wise

The Maternity Unit Dilemma
More have closed, costs are rising
and there’s no answer in sight.

by Ann L. Rappoport, PhD

Maternity care across the Delaware Valley continues on a crisis course, even beyond the economic problems of Philadelphia and other population centers.

The problem is particularly severe in Philadelphia and its four Pennsylvania suburban counties, where since 1997, 18 hospitals have ceased providing maternity care. Between 2004 and 2006, the number of obstetricians/gynecologists practicing in Pennsylvania decreased 11 percent. In southeastern Pennsylvania, the number of OB-Gyns has dropped about 30 percent since 2001.

Meanwhile, the rate of premature births — with their heavier use of medical and financial resources — has been increasing across Delaware, New Jersey, Pennsylvania and in the nation as a whole. The infant mortality rate in Philadelphia is increasing and is significantly higher than the national rate. These factors further pressure those hospitals and professionals still providing maternity care and raise additional issues about prenatal care.

Problems remain long and deep, with significant impact on providers, the way maternity care is provided, and on taxpayers, mothers and families.

Problem 1:

Reimbursement Rates

    If 41 percent of the time, you’re reimbursed for only 82 cents of every dollar of your costs, how long will it take you to go broke? These numbers reflect the average Medicaid reimbursement rate and the percentage of births covered by medical assistance in Pennsylvania. Two-thirds of the births in Philadelphia are covered under medical assistance. Nationally, Medicaid reimburses an average of 88 cents on the dollar for births.

Hospitals are often reimbursed for less than two-thirds of their maternity care costs. Experts analyzing insurance data conclude that hospitals in this area lose $2,000-$4,000 per birth.

Of services that hospitals provide, maternity services are disproportionately dependent upon Medicaid. In Pennsylvania, medical assistance pays for approximately 16 percent of all hospital discharges, but accounts for 41 percent of newborn discharges. So to stay in the baby birthing business, hospitals must find a way to cover their losses.

For example, Hahnemann University Hospital passes along its costs to tuition at Drexel University College of Medicine, with which it’s associated. Cooper University Hospital in South Jersey tries to provide services with “better insurance mix” in order to afford to care for the large Medicaid population in Camden.

Problem 2:

Liability Costs

    Even though the overall number of medical malpractice suits in Pennsylvania has dropped in the past five years, Lloyd’s of London calls Philadelphia “the worst liability market in the world,” according to Owen Montgomery, MD, Chief of OB-Gyn service at Hahnemann. The cost of malpractice insurance is an 800-pound gorilla, he says.
Ironically, the costs of lawsuits and legal insurance are not closing other high-risk specialty units such as neurology and cardiology, he notes. Nor are they dramatic factors in markets such as New York City or Boston.

It means few obstetricians in this region remain in private practice. Most, like Robin Perry, MD, Chief of OB-Gyn at Cooper University Hospital, have become hospital employees. Another recourse is for institutions to “self-insure,” an approach taken by Drexel and the University of Pennsylvania.

Liability issues have increased discussion within the profession about designating only certain “laborists” or “hospitalists” to perform births in order to decrease the number of high-risk specialists to insure.

“Defensive medicine” has become reality. One of the most troubling examples is the upward trend of births by surgical Caesarian section. C-section rates “are going nuts,” according to Dr. Perry.

C-sections in New Jersey have reached 40-45 percent. Some circumstances call for surgical intervention, she explains, but nowhere near half. In the short run, birth by Caesarian surgery suggests a sense of control, especially among busy practitioners who are not necessarily experts in fetal monitoring. But looking forward to a decade of this trend, Perry predicts the overall statistics will reveal increased post-operative maternal complications as a result, adding further to costs and liability.

Problem 3:

Preterm Births

    Another troubling trend is the rise in rate of premature births and increased need for neonatal intensive care units (NICU) across the country. It isn’t clear to what extent the increase in premature births results from inadequate prenatal care and poor lifestyle choices, from improved interventions in problem births and neo-natal care, or from other factors.

Whatever the reasons, prematurity adds costs and risks to care, contributing to hospital expenses, as well as exposure to liability, even though the medical personnel and hospital may have performed according to best practices.

A 37-week fetus is not mature, according to Richard Derman, MD, Chair of OB-Gyn at Delaware’s Christiana Care Health System. Waiting until the 39th week for induction or a C-section (unless medically necessary) reduces NICU admissions, he says. “Even one day matters” in improved health for the baby and reduction in costs of care and liability, says Dr. Derman.

Christiana Hospital in Newark, DE delivered 7,100 babies last year and has a high-risk level 3 nursery with 70 NICU beds. As one of the largest maternity units in the country, it is a leader in research. Christiana has been actively collecting data and tracking outcomes to determine best practices of care.

Research helps identify specific procedures that are most successful and can reduce errors and liability. For example, Dr. Derman says a program of injectable progesterone for women with pre-term labor in prior pregnancies is one important way Christiana improves patient outcomes and helps lower liability costs.

Christiana also requires all of its 88 OB-Gyns to be re-trained in the latest protocols for unpredictable events such as shoulder dystocia (when the baby’s shoulder gets stuck on the mother’s pelvic bone during delivery) and post-partum hemorrhaging. “Sticking to strict protocols results in more favorable outcomes,” Derman says. And favorable outcomes are less expensive and less risky, as well.
Additional Issues
Areas with high birth rates do not always coincide with providers of maternity care. For instance, South and Northeast Philadelphia have no maternity units, whereas three hospitals with maternity care are clustered within walking distance of each other in Center City, Dr. Montgomery points out.

This poor geographic distribution of hospital-based maternity care increasingly coincides with inadequate availability of prenatal care in the underserved communities. It results in fewer options for care, longer delays for appointments and increasing difficulty in obtaining healthcare for pregnant patients, according to the Maternity Care Coalition.

Furthermore, when these patients show up for delivery without medical records, hospitals perform costly extra tests. Some existing maternity departments experience overcrowding as they absorb patients affected by the closure of units close to their communities. As providers stretch their capacity, the likelihood of error or “near misses” increases. Inadequate healthcare in the short run compromises outcomes and also becomes more expensive in the long run.

Looking Ahead
As with other complex problems, solving the maternity care crisis requires new approaches on multiple fronts. Some groups advocate for changes in public policy and insurance, some focus on maternal education and others look at research and the delivery of care. Here are some samples.

Licensed nurse midwives have joined the maternity practices of Drexel obstetricians at Hahnemann, resulting in high patient satisfaction, says Dr. Montgomery. Their services cost less than obstetricians, though he explains that’s not the reason they’re integrated into the team.

Practicing in collaboration with obstetricians, nurse midwives “expand the pool of practitioners and access,” says Pamela Clarke, a vice president of the Delaware Valley Healthcare Council. They help to ease the strain on obstetric practices and hospital maternity units.

Some advocates hope birthing centers and prenatal clinics may also help fill in gaps in maternity care. Better prenatal care and healthier mothers can lead to fewer complications — and decreased costs of maternal and newborn care. The Maternity Care Coalition (www.momobile.org), headquartered in Philadelphia, offers services to improve maternal and infant care in southeastern Pennsylvania.

Christiana Hospital is one of the principal sites in a huge new federal study, the National Children’s Study, which will follow babies through adolescence in order to determine specific factors associated with healthy outcomes. Information from this research could identify new ways to improve care, while reducing risks and costs.

Ann L. Rappoport, PhD is an educational consultant and a contributing writer to MetroKids.

Hospitals with Maternity Units

DELAWARE
 • Bayhealth: Kent General, Milford
    Memorial
 • Beebe Medical Center
 • Christiana Care: Christiana Hospital,
    Wilmington Hospital
 • Nanticoke Memorial
 • St. Francis Hospital

PENNSYLVANIA
Bucks County
 • Doylestown Hospital
 • Grand View Hospital
 • Lower Bucks Hospital
 • St. Mary Medical Center

Chester County
 • Chester County Hospital
 • Jennersville Regional Hospital
 • Paoli Hospital
 • Phoenixville Hospital

Delaware County
 • Crozer-Chester Medical Center
 • Delaware County Memorial Hospital
 • Riddle Memorial Hospital

Montgomery County
 • Abington Memorial Hospital
 • Bryn Mawr Hospital
 • Holy Redeemer Health System
 • Lankenau Hospital,
 • Mercy Suburban Hospital
 • Montgomery Hospital Medical Center,
 • Pottstown Memorial Medical Center

Philadelphia
 • Albert Einstein Medical Center
 • Hahnemann University Hospital
 • Hospital of the University of     Pennsylvania,
 • Pennsylvania Hospital
 • Temple University Hospital
 • Thomas Jefferson University Hospital

SOUTH JERSEY
 • Cooper University Hospital
 • Kennedy Memorial Hospital - University 
    Medical Center/Washington Township
 • Our Lady of Lourdes Medical Center and
    Lourdes Medical Center of Burlington
    County
 • South Jersey Healthcare Elmer Hospital
 • Underwood Memorial Hospital
 • Virtua Memorial Hospital and Virtua West
    Jersey Voorhees
Holy Redeemer Plans Bigger Maternity Unit

Holy Redeemer Hospital and Medical Center in Meadowbrook, PA has announced a $10 million expansion and renovation of its Maternity Center of Excellence.

The project, expected to be completed in two years, will increase neonatal intensive care beds from 10 to 19 and enhance the Center’s high-risk maternity unit, triage, nursery, post-partum unit, central nursing station and waiting area.

About 3,000 babies per year are delivered at Holy Redeemer, an increase of 50 percent since 2005. The expansion will accomodate 4,000 births and provide state-of-the art surroundings. http://yourebeautifulbaby.com

13 Years of Southeastern
PA Maternity Unit Closures
 • Medical College of
    Pennsylvania (1997)
 • Germantown (1998)
 • Nazareth (1998)
 • City Avenue (1999)
 • Roxborough (1999)
 • Warminster (2000)
 • Elkins Park (2001)
 • Episcopal (2001)
 • Mercy Philadelphia (2002)
 • Methodist (2002)
 • Mercy Fitzgerald (2003)
 • Parkview (2003)
 • Frankford (2006)
 • Jeanes (2007)
 • Brandywine Hospital (2008)
 • Chestnut Hill Hospital (2008)
 • Central Montgomery Medical
    Center (2009)
 • Temple East-Northeastern
    Hospital (2009)

   

Cesarean sections births may cause genetic changes in babies????

C-section Births Cause Genetic Changes That May Increase Odds For Developing Diseases In Later Life

ScienceDaily (June 29, 2009) — Swedish researchers have discovered that babies born by Caesarean section experience changes to the DNA pool in their white blood cells, which could be connected to altered stress levels during this method of delivery, according to the July issue of Acta Paediatrica.  

It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.

Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.

This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.

“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.

“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”

The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.

“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.

“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after  delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”

The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.

“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”

Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.

“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.

“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”

The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.

  “Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.

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Journal reference:

1. Schlinzig et al. Epigenetic modulation at birth - altered DNA-methylation in white blood cells after Caesarean section. Acta Paediatrica, 2009; 98 (7): 1096 DOI: 10.1111/j.1651-2227.2009.01371.x

Adapted from materials provided by Wiley - Blackwell, via AlphaGalileo.

Web address:
     http://www.sciencedaily.com/releases/2009/06/
     090629081443.htm