Williams Obstetrics, 24th Edition

CHAPTER 1. Overview of Obstetrics

VITAL STATISTICS

PREGNANCY IN THE UNITED STATES

MEASURES OF OBSTETRICAL CARE

TIMELY TOPICS IN OBSTETRICS

Obstetrics is concerned with human reproduction and as such is always a subject of considerable contemporary relevance. The specialty promotes health and well-being of the pregnant woman and her fetus through quality perinatal care. Such care entails appropriate recognition and treatment of complications, supervision of labor and delivery, ensuring care of the newborn, and management of the puerperium. Postpartum care promotes health and provides family planning options.

The importance of obstetrics is reflected by the use of maternal and neonatal outcomes as an index of the quality of health and life among nations. Intuitively, indices that reflect poor obstetrical and perinatal outcomes would lead to the assumption that medical care for the entire population is lacking. With those thoughts, we now provide a synopsis of the current state of maternal and newborn health in the United States as it relates to obstetrics.

VITAL STATISTICS

The National Vital Statistics System of the United States is the oldest and most successful example of intergovernmental data sharing in public health. The National Center for Health Statistics collects and disseminates official statistics through contractual agreements with vital registration systems. These systems that operate in various jurisdictions are legally responsible for registration of births, fetal deaths, deaths, marriages, and divorces. Legal authority resides individually with the 50 states; two regions—the District of Columbia and New York City; and five territories—American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands.

Standard certificates for the registration of live births and deaths were first developed in 1900. An act of Congress in 1902 established the Bureau of the Census to develop a system for the annual collection of vital statistics. The Bureau retained authority until 1946, when the function was transferred to the United States Public Health Service. It is presently assigned to the Division of Vital Statistics of the National Center for Health Statistics, which is a division of the Centers for Disease Control and Prevention (CDC). The standard birth certificate was revised in 1989 to include more information on medical and lifestyle risk factors and obstetrical practices.

In 2003, an extensively revised Standard Certificate of Live Birth was implemented in the United States to enhance collection of obstetrical and newborn clinical information. The enhanced data categories and specific examples of each are summarized in Table 1-1. By 2011, 36 states had implemented this revised birth certificate representing 83 percent of all births (Hamilton, 2012).

TABLE 1-1. General Categories and Specific Examples of New Information Added to the 2003 Revision of the Birth Certificate


Risk Factors in Pregnancy—Examples: prior preterm birth, prior eclampsia

Obstetrical Procedures—Examples: tocolysis, cerclage, external cephalic version

Labor—Examples: noncephalic presentation, glucocorticoids for fetal lung maturation, antibiotics during labor

Delivery—Examples: unsuccessful operative vaginal delivery, trial of labor with prior cesarean

Newborn—Examples: assisted ventilation, surfactant therapy, congenital anomalies

image Definitions

The uniform use of standard definitions is encouraged by the World Health Organization as well as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012). Such uniformity allows data comparison not only between states or regions of the country but also between countries. Still, not all definitions are uniformly applied. For example, the American College of Obstetricians and Gynecologists recommends that reporting include all fetuses and neonates born weighing at minimum 500 g, whether alive or dead. But not all states follow this recommendation. Twenty-eight states stipulate that fetal deaths beginning at 20 weeks’ gestation should be recorded as such; eight states report all products of conception as fetal deaths; and still others use a minimum birthweight of 350 g, 400 g, or 500 g to define fetal death. To further the confusion, the National Vital Statistics Reports tabulates fetal deaths from gestations that are 20 weeks or older (Centers for Disease Control and Prevention, 2009). This is problematic because the 50th percentile for fetal weight at 20 weeks approximates 325 to 350 g—considerably less than the 500-g definition. Indeed, a birthweight of 500 g corresponds closely with the 50th percentile for 22 weeks.

Definitions recommended by the National Center for Health Statistics and the Center for Disease Control and Prevention are as follows:

Perinatal period. The interval between the birth of an infant born after 20 weeks’ gestation and the 28 completed days after that birth. When perinatal rates are based on birthweight, rather than gestational age, it is recommended that the perinatal period be defined as commencing at 500 g.

Birth. The complete expulsion or extraction from the mother of a fetus after 20 weeks’ gestation. As described above, in the absence of accurate dating criteria, fetuses weighing < 500 g are usually not considered as births but rather are termed abortuses for purposes of vital statistics.

Birthweight. The weight of a neonate determined immediately after delivery or as soon thereafter as feasible. It should be expressed to the nearest gram.

Birth rate. The number of live births per 1000 population.

Fertility rate. The number of live births per 1000 females aged 15 through 44 years.

Live birth. The term used to record a birth whenever the newborn at or sometime after birth breathes spontaneously or shows any other sign of life such as a heartbeat or definite spontaneous movement of voluntary muscles. Heartbeats are distinguished from transient cardiac contractions, and respirations are differentiated from fleeting respiratory efforts or gasps.

Stillbirth or fetal death. The absence of signs of life at or after birth.

Early neonatal death. Death of a liveborn neonate during the first 7 days after birth.

Late neonatal death. Death after 7 days but before 29 days.

Stillbirth rate or fetal death rate. The number of stillborn neonates per 1000 neonates born, including live births and stillbirths.

Neonatal mortality rate. The number of neonatal deaths per 1000 live births.

Perinatal mortality rate. The number of stillbirths plus neonatal deaths per 1000 total births.

Infant death. All deaths of liveborn infants from birth through 12 months of age.

Infant mortality rate. The number of infant deaths per 1000 live births.

Low birthweight. A newborn whose weight is < 2500 g.

Very low birthweight. A newborn whose weight is < 1500 g.

Extremely low birthweight. A newborn whose weight is < 1000 g.

Term neonate. A neonate born any time after 37 completed weeks of gestation and up until 42 completed weeks of gestation (260 to 294 days). The American College of Obstetricians and Gynecologists (2013b) and the Society for Maternal-Fetal Medicine endorse and encourage specific gestational age designations. Early term refers to neonates born at 37 completed weeks up to 386/7 weeks. Full termdenotes those born at 39 completed weeks up to 406/7weeks. Last, late term describes neonates born at 41 completed weeks up to 416/7 weeks.

Preterm neonate. A neonate born before 37 completed weeks (the 259th day).

Postterm neonate. A neonate born anytime after completion of the 42nd week, beginning with day 295.

Abortus. A fetus or embryo removed or expelled from the uterus during the first half of gestation—20 weeks or less, or in the absence of accurate dating criteria, born weighing < 500 g.

Induced termination of pregnancy. The purposeful interruption of an intrauterine pregnancy that has the intention other than to produce a liveborn neonate and that does not result in a live birth. This definition excludes retention of products of conception following fetal death.

Direct maternal death. The death of the mother that results from obstetrical complications of pregnancy, labor, or the puerperium and from interventions, omissions, incorrect treatment, or a chain of events resulting from any of these factors. An example is maternal death from exsanguination after uterine rupture.

Indirect maternal death. A maternal death that is not directly due to an obstetrical cause. Death results from previously existing disease or a disease developing during pregnancy, labor, or the puerperium that was aggravated by maternal physiological adaptation to pregnancy. An example is maternal death from complications of mitral valve stenosis.

Nonmaternal death. Death of the mother that results from accidental or incidental causes not related to pregnancy. An example is death from an automobile accident or concurrent malignancy.

Maternal mortality ratio. The number of maternal deaths that result from the reproductive process per 100,000 live births. Used more commonly, but less accurately, are the terms maternal mortality rate or maternal death rate. The term ratio is more accurate because it includes in the numerator the number of deaths regardless of pregnancy outcome—for example, live births, stillbirths, and ectopic pregnancies—whereas the denominator includes the number of live births.

Pregnancy-associated death. The death of a woman, from any cause, while pregnant or within 1 calendar year of termination of pregnancy, regardless of the duration and the site of pregnancy.

Pregnancy-related death. A pregnancy-associated death that results from: (1) complications of pregnancy itself, (2) the chain of events initiated by pregnancy that led to death, or (3) aggravation of an unrelated condition by the physiological or pharmacological effects of pregnancy and that subsequently caused death.

PREGNANCY IN THE UNITED STATES

image Pregnancy Rates

Data from diverse sources have been used to provide the following snapshot of pregnancy in the United States during the first two decades of the 21st century. According to the Centers for Disease Control and Prevention, the fertility rate in the United States in 2011 of women aged 15 to 44 years was 63.2 live births per 1000 women (Sutton, 2011). As shown in Figure 1-1, this rate began slowly trending downward in 1990 and has now decreased below that for replacement births, indicating a population decline (Hamilton, 2012). There were 3.9 million births in 2011, and this constituted the lowest birth rate ever recorded for the United States of 12.7 per 1000 population. The birth rate decreased for all major ethnic and racial groups, for adolescents and unmarried women, and for those aged 20 to 24 years. For women older than 30 years, the birth rate was either unchanged or it increased slightly. Virtually half of newborns in 2010 in the United States were minorities: Hispanic—25 percent, African-American—14 percent, and Asian—4 percent (Frey, 2011).

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FIGURE 1-1 Fertility rate: United States, 1925–2009. (From Sutton, 2011.)

The total number of pregnancies and their outcomes in 2008 are shown in Table 1-2. Of the 6,578,000 total pregnancies, most—65 percent—ended with live births. Of births in the United States, approximately 37 percent are unintended at the time of conception (Mosher, 2012). Importantly, the overall proportion of unintended births has not declined significantly since 1982. Unmarried women, black women, and women with less education or income are more likely to have unplanned pregnancies. That said, of the remaining pregnancies in 2008, 35 percent were almost equally divided into induced or spontaneous abortions. The induced abortion information is based on CDC abortion surveillance data from 45 states combined with Guttmacher Institute data on induced abortion. These data have been collected beginning in 1976. If the annual totals for 1976 to 2008 are tabulated, it can be estimated that approximately 46,657,000 women in the United States have elected induced abortions since Roe v. Wade legalization of abortion (Chap. 18p. 363). Thus, legalized abortions have been chosen by more than 46 million American women. As discussed later, this provides a compelling argument for easily accessible family planning.

TABLE 1-2. Total Number of Pregnancies and Outcomes in the United States in 2008

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MEASURES OF OBSTETRICAL CARE

image Perinatal Mortality

There are a number of indices—several among the vital statistic definitions described above—that are used as a yardstick of obstetrical and perinatal outcomes to assess quality of care.

As previously defined, the perinatal mortality rate includes the numbers of stillbirths and neonatal deaths per 1000 total births. According to the National Vital Statistics Reports by MacDorman and colleagues (2012a), the perinatal mortality rate in 2006 was 10.5 per 1000 births (Fig. 1-2). There were 25,972 fetal deaths in gestations 20 weeks or older. Fetal deaths at 28 weeks or more have been declining since 1990, whereas the rates for those between 20 and 27 weeks have been static (Fig. 1-3). By way of comparison, there were a total of 19,041 neonatal deaths in 2006—meaning that nearly 60 percent of the perinatal deaths in the United States were fetal. Thus, it is seen that fetal deaths have eclipsed neonatal deaths as a cause of perinatal mortality.

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FIGURE 1-2 Perinatal mortality rate: United States, 1990–2006. Perinatal includes infant deaths under age 28 days and fetal deaths at 20 weeks or more. (From MacDorman, 2012a.)

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FIGURE 1-3 Fetal mortality rates by period of gestation: United States, 1990–2006. (From MacDorman, 2012a.)

image Infant Deaths

There were 6.1 infant deaths per 1000 live births in 2011 compared with 6.8 in 2001 (Hamilton, 2012). The three leading causes of infant death—congenital malformations, low birthweight, and sudden infant death syndrome—accounted for almost half of all deaths. Infants born at the lowest gestational ages and birthweights add substantively to these mortality rates. For example, 55 percent of all infant deaths in 2005 were in the 2 percent of infants born before 32 weeks’ gestation. Indeed, the percentage of infant deaths related to preterm birth increased from 34.6 percent in 2000 to 36.5 percent in 2005. When analyzed by birthweight, two thirds of infant deaths were in low-birthweight neonates. Of particular interest are those birthweights < 500 g, for which neonatal intensive care can now be offered. In 2001, there were 6450 liveborns weighing less than 500 g, but 86 percent of these newborns died during the first 28 days of life. Of the 1044 who survived the first 28 days of life, there were 934 who lived for at least 1 year. Thus, only 14 percent of all neonates weighing < 500 g survived infancy. Importantly, adverse developmental and neurological sequelae are common in the survivors (Chap. 42p. 832).

More than a decade ago, St. John and associates (2000) estimated the total cost of initial newborn care in the United States to be $10.2 billion annually. Almost 60 percent of this expenditure is attributed to preterm births before 37 weeks, and 12 percent is spent on neonates born between 24 and 26 weeks.

image Maternal Mortality

As shown in Figure 1-4, maternal mortality rates decreased precipitously in the United States during the 20th century. Pregnancy and childbirth have never been safer for women in this country. In fact, pregnancy-related deaths are so uncommon as to be measured per 100,000 births. The CDC since 1979 has maintained data on pregnancy-related deaths in its Pregnancy Mortality Surveillance System(Mackay, 2005). In the latest report, Berg and coworkers (2010) described 4693 pregnancy-related deaths during the 8-year period 1998 to 2005. Approximately 5 percent were early-pregnancy deaths due to ectopic gestation or abortive outcomes. The deadly obstetrical triad of hemorrhage, preeclampsia, and infection accounted for a third of all deaths (Table 1-3). Thromboembolism, cardiomyopathy, and other cardiovascular disease together accounted for another third (Fig. 1-5). Other significant contributors in this group were amnionic fluid embolism (7.5 percent) and cerebrovascular accidents (6.3 percent). Anesthesia-related deaths were at an all-time low of only 1.2 percent. It is also important to consider the role that the increasing cesarean delivery rate has on maternal mortality risks (Clark, 2008; Deneux-Tharaux, 2006; Lang, 2008).

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FIGURE 1-4 Maternal mortality rates for the United States, 1950–2003. (Data from Berg, 2010; Hoyert, 2007.)

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FIGURE 1-5 Six common causes of maternal deaths for the United States, 1998–2005. (Data from Berg, 2010.)

TABLE 1-3. Causes of Pregnancy-Related Maternal Deaths in the United Statesa,b During Two Time Periods

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The pregnancy-related mortality ratio for this 1998 to 2005 period of 14.5 per 100,000 live births is the highest during the previous 20 years (Berg, 2010). This simply may mean more women are dying, however, it may be due to improved reporting or to an artificial increase caused by the new International Statistical Classification of Diseases, 10th Revision (ICD-10), implemented in 1999. There is no doubt that maternal deaths are notoriously underreported, possibly by as much as half (Koonin, 1997).

A second important consideration is the obvious disparity of increased mortality rates in African-American compared with white women as shown in Figure 1-6. The disparity with indigent women is exemplified by the study of maternal deaths in women cared for in a third-party payer system, the Hospital Corporation of America. In this study of nearly 1.5 million pregnant women, Clark and associates (2008) reported an impressively low maternal mortality rate of 6.5 per 100,000.

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FIGURE 1-6 Maternal mortality ratio—deaths per 100,000 live births—by age and according to race for the United States, 1998–2005. (Data from Berg, 2010.)

The third important consideration is that many of the reported maternal deaths are considered preventable. In an earlier report, Berg and colleagues (2005) stated that this may be up to a third of pregnancy-related deaths in white women and up to half of those in African-American women. And even in the insured women described above and reported by Clark, 28 percent of 98 maternal deaths were judged preventable. Thus, although significant progress has been made, measures to prevent more deaths are imperative for obstetrics in the 21st century.

image Severe Maternal Morbidity

Because maternal deaths have become so uncommon, the practice of analyzing severe maternal morbidity evolved as a surrogate to improve obstetrical and perinatal care. Because avoidance of medical errors serves to decrease the risks for maternal mortality or severe maternal morbidity, the concept of near misses or close calls was also introduced. These are defined by the Joint Commission and the Institution for Safe Medication and Practices (2009) as unplanned events caused by error that do not result in patient injury but have the potential to do so. These are much more common than injury events, but for obvious reasons, they are more difficult to identify and quantify. Systems designed to encourage reporting have been installed in various institutions and allow focused safety efforts. One example is the system described by Clark and associates (2012) and used for more than 200,000 annual deliveries within the Hospital Corporation of America (Table 1-4).

TABLE 1-4. Near-Miss Events in Labor and Delivery—Hospital Corporation of America, 2010

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There are now a number of statistical data systems that measure indicators of unplanned events caused by errors that had potential to injure patients. This evolution followed inadequacies in how well hospitalization coding reflected the severity of maternal complications. Thus, coding indicators or modifiers are used to allow analysis of serious adverse clinical events (Clark, 2012; King, 2012). Such a system was implemented by the World Health Organization. It has been validated in Brazil and accurately reflects maternal death rates (Souza, 2012). Similar systems are in use in Britain as the UK Obstetric Surveillance System—UKOSS (Knight, 2005, 2008). Australia and New Zealand have also devised such a system—the Australasian Maternity Outcomes Surveillance System—AMOSS (Halliday, 2013). As emphasized by Tuncalp and coworkers (2012) after their systematic review, different locoregional approaches are needed to lower the rates of near misses.

In the United States, to study severe morbidity the CDC analyzed more than 50 million maternity records from the Nationwide Inpatient Sample from 1998 to 2009 (Callaghan, 2012). Selected International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to tabulate a number of severe morbidities. The frequencies of some of those most commonly encountered are listed in Table 1-5. These investigators reported that 129 per 10,000 of these nearly 50 million pregnant women had at least one indicator for severe morbidity. Thus, for every maternal death, approximately 200 women experience severe morbidity.

TABLE 1-5. Severe Obstetrical Morbidities Identifieda During Nearly 50 Million Hospitalizations for Delivery—United States, 1998–2009

Category

Transfusions

Eclampsia

Hysterectomy

Cardiac surgery

Cerebrovascular disorders

Anesthesia complications

Pulmonary edema

Mechanical ventilation

Respiratory distress syndrome

Septicemia

Heart failure

Renal failure

Coagulopathy

Hemorrhagic shock

aIdentified by International Classification of Diseases, 9th

Revision, Clinical Modification (ICD-9-CM) codes.

Data from Callaghan, 2012.

TIMELY TOPICS IN OBSTETRICS

image Health Care for Women and Their Infants

Various topics have been in the forefront for obstetrical providers in the 4 years since the last edition of this textbook. Of these, the ills of our health-care system are especially concerning for women’s health (Hale, 2010). To cite but a few examples, uninsured women with breast cancer were up to 50 percent more likely than insured women to die from the disease. There were more than 17 million uninsured American women aged 18 to 64 years in 2008. Similarly, women without health-care insurance had a 60-percent greater risk of late-stage cervical cancer. Lack of medical insurance also has severe effects on pregnant women. Those without insurance have a 31-percent higher risk of adverse outcomes such as preterm delivery, neonatal death, and maternal mortality. Of American women aged 18 to 64 years in a recent study of 11 industrialized countries, 43 percent skipped seeing a doctor or did not take medicine due to costs (Robertson, 2012). This was the highest percentage of all 11 countries studied. By comparison, just 7 percent of British women and 17 percent of Canadian and French women refrained from seeking health care because of costs. Of the 11 countries studied, only the United States did not have universal health-care coverage.

There is also a geopolitical consequence of such increased adverse outcomes for American women. The World Health Organization analyzed neonatal mortality rates in 2009 for 193 countries (Oestergaard, 2011). The United States ranked 41st in 2009, dropping from 28th in 1990. The highest newborn death rate in the world was in Afghanistan, where one of every 19 babies died before their 1-month birthday. In comparison, one of every 233 newborns dies in the United States. This is far better than the rate in Afghanistan, but not as good as the rate in Japan—1 in 909, France—1 in 455, Lithuania—1 in 385, or Cuba—1 in 345. Some reasons given for the United States results include difficulty in accessing prenatal care, which contributes to the current high rate of preterm births.

There have been dramatic changes in women’s health care regarding obstetrical and gynecological procedures during the past 30 years in the United States. Shown in Figure 1-7 are the rates per 1000 adult American women for the commonest gynecological procedures performed between 1979 and 2006. The rates are adjusted for age to correct for population changes over time. The dramatic decreases in the rates of gynecological procedures were thought largely due to changed criteria for these procedures. Changed criteria resulted from the health maintenance organization (HMO) movement of the 1980s. With this, health-care insurers of all types exercised increasing control over the indications for these procedures. Shown in Figure 1-8 are the rates per 1000 adult women for obstetrical procedures also from 1979 to 2006. Episiotomy use plummeted, as did operative vaginal delivery rates. Cesarean deliveries per 1000 women greatly increased. These rates changes are discussed more fully in Chapters 2729, and 30, which cover these delivery routes.

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FIGURE 1-7 Age-adjusted rates of gynecological procedures in the United States, 1979–2006. (Data from Oliphant, 2010.)

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FIGURE 1-8 Age-adjusted rates of obstetrical procedures in the United States, 1979–2006. (Data from Oliphant, 2010.)

There are only two federal programs dedicated solely to health care of women and their infants, and every obstetrician should know about these programs (Lu, 2012). The first is the Title V Maternal and Child Health Services Block Grant, which is the only federal program focused on improving the health of mothers, children, and their families. It was enacted by Congress in 1935 as part of the Social Security Act. Title V provides for state-level block grants in which states match with $3 every $4 in federal money. In 2009, states reported that 2.5 million primarily low-income pregnant women and 35 million children were served by these state block grants.

The second federal program dedicated to women’s health care is the Title X Family Planning Program. This is the only federal program focused on providing women with comprehensive family planning and related preventative health services. Title X was enacted in 1970, and in 2010, it served more than 5.2 million primarily low-income women.

Beginning with implementation of the 2003 United States Standard Birth Certificate described earlier, the principal source of payment for births was reported. In 2010, it was estimated that Medicaid financed 48 percent of the births in the United States (Markus, 2013). Importantly, Medicaid covered a disproportionate number of complicated births. Specifically, Medicaid paid for more than half of all hospital stays for preterm and low-birthweight infants and approximately 45 percent of infant hospital stays due to birth defects.

So, what is the “bottom line” for obstetrical health care in the United States for women and their infants? In 2008, the total national hospital bill was almost $1.2 trillion (Wier, 2011). These charges involved 39.9 million hospital stays but do not include outpatient care, emergency care for patients not admitted to the hospital, or physician fees. Medicare and Medicaid paid for 60 percent of the 2008 national hospital bill. Specifically, Medicare covered 46.2 percent and Medicaid 13.8 percent. The hospital bills for the mother’s pregnancy and delivery plus care of the newborn exceeded $98 billion, representing 8 percent of all hospital bills. This bill for women and their infants is more than twice that of any other diagnosis across the entire spectrum of American health care and attests to the impact of health care for pregnant women in this country.

image The Affordable Care Act

In the last edition of Williams Obstetrics, the Obama Administration was poised to pass universal health insurance—so-called Obamacare. This history-making legislation debuted on March 23, 2010, with passage into law of The Patient Protection and Affordable Care Act—PPACA. Although constitutional challenges followed, the Supreme Court upheld most aspects of the law in its ruling in 2012 of National Federation of Independent Business v. Sebelius. Implementation of this complex legislation began in 2010 and will continue over the current decade (Fig. 1-9). Indeed, initially registration began with a rocky start in late 2013.

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FIGURE 1-9 Timeline for implementation of provisions of the Patient Protection and Affordable Care Act. (From Oberlander, 2012, with permission.)

As outlined by the Society for Maternal-Fetal Medicine, the act will expand obstetrical care of indigent women (Grande, 2013). The American College of Obstetricians and Gynecologists (2013a) estimates that nearly 20 million uninsured women aged 18 to 64 years have less than optimal access to prenatal care, family planning services, and breast and cervical cancer screening. Many of these women will have improved access to these services because of the expanded Medicaid coverage funded through the Act. The College encourages individual states to expand their Medicaid coverage and improve reimbursement rates.

One “fly in the ointment” of the Affordable Care Act is funding. Although it has been declared “budget neutral,” the Congressional Budget Office has calculated that 30 million Americans will remain uninsured. For these and a multitude of fiscal reasons—and we certainly do not profess to be economists—we, like Oberlander (2012) and others, remain nervous concerning costs and adequate funding for “universal health care.”

image Rising Cesarean Delivery Rate

In 2009, the cesarean delivery rate climbed to the highest level ever reported in the United States—32.9 percent (Centers for Disease Control and Prevention, 2013). After that, it appears to have stabilized. This rise in the total rate was a result of upward trends in both the primary and the repeat cesarean delivery rates. Indeed, more than 90 percent of women with a prior cesarean delivery now undergo a repeat procedure. The forces involved in these changes in cesarean delivery rates are multi-factorial and complex. We cite a few examples:

1. The major indication for primary cesarean delivery is dystocia, and there is evidence that this diagnosis has increased. This is discussed in Chapter 23 (p. 455).

2. The sharp decline in vaginal births after cesarean (VBAC) delivery is closely related to the uterine rupture risk associated labor with a prior uterine incision. This is discussed throughout Chapter 31.

3. The controversial cesarean delivery on maternal request (CDMR) contributes to the rise. This is defined as a cesarean delivery at term for a singleton pregnancy on maternal request in the absence of any medical or obstetrical indication (Reddy, 2006). This is discussed in Chapter 30 (p. 589).

4. Near-term and term pregnancy labor induction is commonplace, and failed inductions contribute to the cesarean delivery rate. This is discussed in Chapter 26 (p. 524).

It is not possible to precisely measure the contribution of each of these components to the all-time-high cesarean delivery rate. The American College of Obstetricians and Gynecologists and the Maternal-Fetal Medicine Units Network have addressed these in an attempt to curtail the rising rate. The National Institute of Child Health and Human Development convened a State-of-the-Science Conference in 2006 to provide an in-depth evaluation of the evidence regarding cesarean delivery on maternal request. To date, there have been no evidence-based guidelines. Recognizing that repeat operations constitute a large percentage of cesarean deliveries, the National Institutes of Health (2010) convened a consensus conference entitled Vaginal Birth after Cesarean: New Insights. The findings are discussed in detail in Chapter 31 (p. 609), but to summarize, they supported a trial of labor for many selected women with a prior cesarean hysterotomy scar and recommended that this option be made more available. It is too early to conclude if this recommendation has significantly altered the cesarean delivery rate.

image Genomic Technology

Recent breakthroughs in fetal testing and diagnosis are truly stunning. In one recent issue of the New England Journal of Medicine, there were three reports in which prenatal gene microarray techniques were used for clinical management (Dugoff, 2012). The advantages of these techniques are outlined in Chapters 13 and 14. Wapner and coworkers (2012) compared microarray analysis of maternal blood with karyotyping for chromosomal anomalies. Reddy and associates (2012) applied this technology to stillbirth evaluation and reported it to be superior to karyotyping. The third report by Talkowski and colleagues (2012) described whole-genome sequencing of a fetus using maternal blood.

Added to these possibilities is the specter of made-to-order embryos (Cohen, 2013). These are but a few examples that illustrate the power of genomic technology to pursue fetal diagnosis and possible therapy. At this juncture, there are complex obstacles to overcome, but with rapid advancement of these technologies, success is almost assured.

image Electronic Health Records

Rising costs, inconsistent quality, and patient safety issues are significant challenges to the delivery of health care in the United States. Electronic health records (EHR) have been identified as a means of improving provider efficiency and effectiveness (Jha, 2009). Methods to speed the adoption of health information technology have received bipartisan support in Congress, and the American Recovery and Reinvestment Act of 2009 has made such a system a national priority. This was soon followed by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Recent surveys indicate that approximately half of outpatient practices and hospitals in the United States are now using EHR. This act also introduced the concept of “meaningful use” EHRs by providers. Classen and Bates (2011) appropriately note, however, that “meaningful use” does not necessarily equate with “meaningful benefits.” According to the American College of Obstetricians and Gynecologists (2010), studies of effectiveness are critically needed to justify the safe implementation of these costly electronic computerized systems.

image Health-Care Outcomes Research

Although per capita health-care expenditures in the United States are the highest in the world, health-care outcomes frequently lag behind those in nations spending far less. A major factor in this disparity is thought to be expenditure overuse, underuse, and misuse driven by rationale-based instead of evidence-based health care. Buried within the 2400 pages of the landmark health-care reform bill signed into law by President Barack Obama are several provisions that touch on clinical research (Kaiser, 2010). Two are aimed at determining which health-care interventions work best and identifying financial conflicts of researchers. A third provision funds acceleration of new drug development. Proponents hope these research studies will improve the quality and lower the cost of health care by identifying the best treatments. We applaud this effort. Indeed, we are of the view that systematic prospective measurement of health-care outcomes as related to treatments prescribed should be an on-going requirement for the practice of medicine.

Much publicity followed the report by the Institute of Medicine entitled To Err Is Human (Kohn, 2000). This report greatly increased interest in measuring health-care outcomes and adverse events (Grobman, 2006). Even the United States Congress has determined that reimbursements by Medicare and Medicaid should be indexed to selected health-care outcomes. Specifically, a wide, often dizzying spectrum of benchmarks has been proposed to measure the quality and safety of obstetrical care. In our view, the greatest impediment to deriving meaningful measures of obstetrical care is the continued use of administrative and financial data—instead of clinical data—to set benchmarks for outcomes.

Regulatory bodies typically evaluate hospital quality using obstetrical outcomes derived from administrative (financial) datasets not designed to measure clinical results. Accordingly, the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development undertook an unprecedented and unparalleled study of obstetrical outcomes based on carefully collected clinical data (Bailit, 2013). The purpose was to establish risk-adjusted models for five obstetrical outcomes and then determine if hospital performance could be reliably measured so that hospitals could be compared. Outcomes studied included postpartum hemorrhage, peripartum infection, severe perineal laceration, neonatal morbidity, and venous thromboembolism. This study included 115,502 mother-infant pairs managed for 3 years at 25 hospitals. Clinical data were abstracted from medical records by specially trained research nurses using a prespecified manual of operations. The study clearly demonstrated that differences between obstetrical outcomes at different hospitals, when clinically adjusted for preexisting patient characteristics, cannot be used to accurately compare obstetrical care among hospitals.

So, what does this mean? It means that the widespread current practice of ranking obstetrical care at different hospitals based on single outcomes, such as third- or fourth-degree perineal lacerations, is useless when accurate data are used. Moreover, use of up to four obstetrical outcomes did not improve the ability to rank hospitals. Actually, use of more than one outcome greatly confused the ranking. A given hospital might rank number one out of 25 hospitals for one obstetrical outcome and 25 out of 25 for a second outcome. Thus, a given hospital could be both very good and very bad depending on the obstetrical outcome analyzed!

image Medical Liability

Approximately 12 percent of obstetrician-gynecologists had at least one malpractice claim each year from 1991 through 2005 (Jena, 2011). The American College of Obstetricians and Gynecologists periodically surveys its fellows concerning the effect of liability on their practice. The 2012 Survey on Professional Liability is the 11th such survey since 1983 (Klagholz, 2012). The survey reflects experiences of more than 9000 members, and 58 percent of these fellows responded that some aspect(s) of the liability environment had caused them to alter their practice since the last survey. Undoubtedly not all of these changes were positive. Those cited included an increased cesarean delivery rate, fewer trials of labor after a prior cesarean delivery, and a decreased number of high-risk patients and total deliveries (Amon, 2014). Others have chosen to forego obstetrical practice entirely. Some of these changes have been linked to states with higher liability premiums (Zwecker, 2011).

Thus, by all accounts, there is still a “liability crisis,” and the reasons for it are complex. Because it is largely driven by money and politics, a consensus seems unlikely. Although some interests are diametrically opposite, other factors contribute to the complexity of the crisis. For example, each state has its own laws and opinions of “tort reform.” Meanwhile, liability claims remain a “hot button” in obstetrics because of their inherent adversarial nature and the sometimes outlandish plaintiff verdicts that contribute to increasing liability insurance premiums. In some states, annual premiums for obstetricians approach $300,000—expenses that at least partially are borne by the patient and certainly by the entire health-care system. Liability issues are daunting, and in 2008, all tort costs in the United States totaled nearly $255 billion. This is an astounding 1.8 percent of the gross domestic product and averages $838 per citizen (Towers Perrin, 2009). Annas (2013) has provided an interesting review of two centuries of malpractice law history. Interestingly, he compares medical malpractice litigation to the white whale in Melville’s Moby-Dick—evil, ubiquitous, and seemingly immoral!

The American College of Obstetricians and Gynecologists has taken a lead in adopting a fair system for malpractice litigation—or maloccurrence litigation. The Committee on Professional Liability has produced several related documents that help fellows cope with the stresses of litigation, that provide advice for the obstetrician giving expert testimony, and that outline recommendations for disclosure of any adverse events (American College of Obstetricians and Gynecologists, 2013c,d,e).

National liability reform likely will come in some form with the push for universal medical insurance coverage. President Obama, in his 2009 address to the American Medical Association, indicated that national malpractice liability reform was negotiable. United States Congressman Michael Burgess—an obstetrician-gynecologist—asked the president to reaffirm this commitment. We applaud these efforts and wish for their success.

image Home Births

Following a slight decline from 1990 through 2004, according to the National Center for Health Statistics, the percentage of home births in the United States increased from 0.56 to 0.72 percent—almost 70 percent—through 2009 (MacDorman, 2012b). But, as is so often the case with data analysis, the “devil is in the details.” Only 62 percent of these 24,970 home births were attended by midwives—19 percent by certified nurse midwives and 43 percent by so-called lay midwives with minimal formal training. The remaining 38 percent of home births were unplanned—that is, the result of accidental delivery at home attended by a family member or emergency medical technician. So is home birth a good idea? Those currently conducted in the United States in which women are not attended by trained and certified personnel cannot be considered acceptable. There have been no randomized trials to test the safety of home deliveries (Olsen, 2012). Proponents of home births cite success from laudatory observational data from European countries such as England and The Netherlands (Van der Kooy, 2011). Data from the United States, however, are less convincing and indicate a higher incidence of perinatal morbidity and mortality (Grünebaum, 2013, 2014; Wasden, 2014; Wax, 2010). These findings have led Chervenak and coworkers (2013) to question the ethics of participation in planned home births.

image Family Planning Services

Politics and religion over the years have led to various governmental interferences with the reproductive rights of women. These intrusions have disparately affected indigent women and adolescents. One example was the consideration by Congress in 1998 for the Title X Parental Notification Act. Reddy and colleagues (2002) estimated this bill would have dissuaded almost half of adolescents younger than 17 years from seeking contraceptive services and care for sexually transmitted disease.

Another example is the tug-of-war over emergency contraception, and more specifically over the morning-after pill (Chap. 38p. 714). Efforts begun in 2004 by the Bush Administration to curtail Plan B for over-the-counter sales to women 17 years and younger was decried appropriately by editorials in the New England Journal of Medicine (Drazen, 2004; Steinbrook, 2004). This issue was not settled until April 2013 when a federal district court in New York ordered the Food and Drug Administration to make emergency contraception available for over-the-counter sales to all women regardless of age. The decision was quickly applauded by the American College of Obstetricians and Gynecologists (2013f). The decision was editorialized as “science prevails” in a subsequent issue of Nature (2013).

Perhaps the most egregious example of both federal and state governmental intrusion into women’s reproductive rights is the often poor availability of federally funded family planning services for indigent women. This is despite all reports of the overwhelming success of such programs. According to the Guttmacher Institute, publicly funded family planning services in 2010 prevented nearly 2.2 million unintended pregnancies and 760,000 abortions in the United States. They concluded that without such funding the abortion rate would be nearly two-thirds higher for all women, and nearly 70-percent higher for adolescents (Frost, 2013). The American College of Obstetricians and Gynecologists (2012) has recently reviewed these and other barriers to emergency contraception access.

image Abortion

It continues to be a preventable fact that up to a fifth of pregnancies in this country are terminated by elective abortion (see Table 1-1). According to the American College of Obstetricians and Gynecologists (2011): “The most effective way to reduce the number of abortions is to prevent unwanted and unintended pregnancies.” Importantly, the negative attitudes, beliefs, and policies toward family planning services and sex education discussed above have helped to contribute to the more than 800,000 abortions performed yearly in the United States.

The history of legislative regulation and federal court decisions regarding abortions is considered in Chapter 18 (p. 363). The Partial Birth Abortion Ban Act of 2003 has become law, and in 2007, the Supreme Court ruled that the ban—officially known as Gonzales v. Carhart—is constitutional. This again caused editorialists in the New England Journal of Medicine to decry the intrusion of government into medicine (Charo, 2007; Drazen, 2007; Greene, 2007). More ominous are restrictive state laws—many of which have been or will be ruled unconstitutional—which according to some will drive Roe v. Wadeback to the Supreme Court.

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