Stakeholders Speak

The first session of Maternity Care Coalition’s (MCC) 2005 conference series, Childbirth at a Crossroads:

Stakeholders Speak

Stakeholders Speak was held March 8th at the College of Physicians in Philadelphia, PA. At this community forum, stakeholders, policymakers, and practitioners discussed the question: Is there a healthcare crisis affecting prenatal and obstetric services today? Through presentations and group discussions, participants examined the state of pregnancy, childbirth, and the healthcare system in the region.

Nia Wilson, Maternity Care Coalition Board member, welcomed the audience and introduced the session moderator, Amy Freeze. Amy, a meteorologist from NBC10, discussed the importance of this topic to her

both professionally and personally. At NBC10, in addition to being a meteorologist she covers features on community issues and pledged to bring the messages and lessons learned from today’s sessions back to the newsroom. Personally, Amy comes from a long-line of family members who are practitioners in OB/GYN fields. She is also a mother of two children whose entrance into her life has greatly affected her and her family.

Amy next introduced Wanda Mial, MCC Board Member and Senior Associate for Child Welfare at the Annie E. Casey Foundation. As we discuss the changing arena of childbirth and

MCC Board Member Wanda Mial

emerging healthcare gaps for women and families, Wanda reminded the audience that Maternity Care Coalition works to bring the voices of these families to policymakers. To this end, Wanda introduced three women to share their stories.

Kathleen Furin shared that having a natural, vaginal birth was very important to her. At 32 weeks, she learned that her second baby was breech, but no providers would help her deliver vaginally. She decided to seek out alternative treatments, and through these treatments she was able to naturally turn her baby and deliver vaginally. However, her insurance company would provide no coverage for these alternative treatments while it would have fully covered her C-section. Being able to deliver her baby in the way that she wanted was empowering to Kathleen, but it was frustrating that no providers or insurance companies supported her in this decision.

Dianne Harriell was the next woman to share her story. Dianne has two children. Her first pregnancy was easy, but she had problems during the birth. Her second pregnancy was more difficult, and her labor was also challenging. Her placenta wouldn’t come out and she had to have it surgically removed. During the birth, her mother and her baby’s father supported her, and her nurse stayed with her during the entire birth, even staying past her shift to see Dianne through her delivery.

Latisha Allen-Neal has four children. For her first child, she had a difficult pregnancy. She was sick often and lost a good deal of weight. She received her prenatal care at a local hospital and had a positive experience there. For her third pregnancy, she switched to a different hospital for her prenatal care. The prenatal care was positive, but she suffered a miscarriage, and experienced insensitivity from practitioners. For her fourth child her prenatal care was good but during birth she found that her doctors were in and out and her anesthesiologist was not attentive.

The next speaker, Dr. Ann Honebrink, Chair of the Pennsylvania Section of the American College of Obstetricians and Gynecologists (ACOG). shared the Ob-Gyn perspective on childbirth in this region. Ann

Dr. Anne Honebrink

reported that there are fewer ob-gyns practicing in Pennsylvania because of skyrocketing liability insurance payments, decreasing compensation, and decreased incentives and time to care for the underinsured and uninsured. Because of these barriers, fewer and fewer people are choosing to enter into the OB field, and more doctors are leaving the field.

Data shows, Ann continued, that there has been a 100% increase in insurance premiums in the last 10 years and fewer insurance companies are will to write insurance for obstetricians. According to an ACOG survey, from 1999 to 2004 1 in 7 obstetricians left the OB field, and 13% are no longer doing major gynecological surgery. In the Unites States, 76% of ob-gyns have been sued at least once.

It is difficult to find data on how many doctors are actually practicing OB, and if there is a shortage of care. The Pennsylvania section of ACOG has embarked on a major survey of hospitals that still deliver babies to get accurate delivery and OB statistics for the state, but we do know that many women in Pennsylvania do not get adequate prenatal care. From FY2002-FY2003, the number of women at the Hospital of the University of Pennsylvania who did not receive prenatal care went up markedly. We also know that from 1997-2003 Central Philadelphia has lost 120 OB beds, while the birthrate has stayed the same, and that those hospitals with a lower birth volume will be soon schedule for closure. Ob-gyn residency applications are down nationwide, and there is a loss of research training in the OB field due to insurance concerns. These issues, Ann concluded, are not unfixable. With meaningful tort reform, better insurance coverage, and better access we can improve the state of OB care in the region and nationwide.

Bill McCool, Director of the Midwifery Graduate Program at the University of Pennsylvania School of Nursing, discussed 21st Century American Birth and posed the question: Are We in the Midst of a Cultural Change? In the United States today, some childbearing families have less access to services and poorer quality care. Others, however, have embraced the changes in OB care and are happy with their experiences. Why do we face this discrepancy?

Bill McCool

In the United States, there is a new birth culture. Women are relinquishing their power in exchange for pain-free births and the avoidance of perceived health care risks down the road. In the US today, practitioners focus on biomedical statistics and the physical health of the mother and baby. They see themselves as the protector of the mother and baby from a number of healthcare and financial dangers.

There are two pervasive topics in US childbirth culture that Bill addressed. The first was epidurals. The use of epidurals has risen dramatically over the past 15 years, yet many concerns remain over adverse effects of epidurals and it is not clear that women are informed about these effects. There are also socio-cultural concerns - why do women in the United States believe that childbirth has to be a completely pain-free experience? Bill believes that feminism has led to this belief. Women now demand to have multiple choices in their childbirth experiences, and have the right to choose a pain-free birth. Also, in this society, people now clamor for a pain-free existence and are seduced by the wonders of technology.

The second topic that Bill addressed was the prevalence of elective c-sections. From 1991 to 2001, there has been a 67% increase in the primary C-section rate. Bill discussed that women now believe that C-sections are better for their pelvic floor, and that women want to have control over the time of birth. The scheduling of births also eases the schedules of obstetricians and enables them to work on a 9-5 schedule. There are concerns with the alarming rate of C-sections: there are always risk when having major surgery; C-sections can lead to newborn respiratory problems, and Bill is doubtful that there is true informed consent around C-sections.

Childbirth must be viewed in its cultural context, Bill argues. In the US, childbirth has emerged as a medical/surgical event. But where are we headed? We need to be aware of all the cultural forces that affect the childbirth experience, and women need to examine where they want birth in the 21st century to be.

Paula Bussard, Senior Vice President of Policy and Regulatory Services at The Hospital & Healthsystem Association of Pennsylvania, presented next on the perspective of hospitals. Hospitals in Pennsylvania deliver 140,000 births annually. In Pennsylvania, there has been a decline in the number of licensed hospitals and licensed beds. From 1997-2005, there has been a decline in the number of OB units from 148 to 129, with the

Paula Bussard

majority of these closures in urban and rural communities--areas in

which there are higher numbers of uninsured and the poor. While some closures do address inefficiencies in the system, the question that

remains is: have these closures affected access?

Lack of health insurance is a major factor in the closing of hospitals in PA. Today, Wal-Mart is the largest employer in the state. Jobs offered at Wal-Mart and other post-9-11 jobs oftentimes do not provide health insurance for employees. Because of federal and state cuts to Medicaid, there are increased barriers to accessing care, especially preventive care. With new state Medicaid regulations, people have stricter limits on the number of doctor’s and emergency room visits. According to Paula, these policies are a rationing of care to save money. These cuts affect the hospitals that serve the most Medicaid patients the most significantly.

Medical liability is another factor leading to declining services in PA. One in four hospitals in the state have shifted or limited services as a result of medical liability.

More can be done to support Pennsylvania hospitals. We can make PA more physician-friendly, stabilize funding to subsidize liability insurance, and increase the number of insured individuals. For maternity care, we need a community view. We need to ensure better access to care and improve the quality of care. The way that a society cares for pregnant women and their newborns is reflective of how the broader society and culture values health care.

The final speaker of the session was Donna Cooper, Secretary of the Office of Policy and Planning for Governor Ed Rendell. Donna began her presentation by reminding the audience that access to prenatal and postpartum care cannot be separated from the fact that the United States does not have national health insurance. More and more, the private sector is raising the question – how can the U.S. be competitive in the globalized economy without national health insurance? There will be more national conversations about this issue as the cost to employers for health insurance continues to rise. The only people benefiting from this situation, Donna asserted, are the malpractice lawyers. In Philadelphia, for example,

Donna Cooper

malpractice settlements are extremely high, as are the malpractice insurance rates. Because we live in such a litigious society, it is becoming increasingly challenging to encourage doctors to enter into the OB-GYN field.

In Pennsylvania, the state government uses the tax on cigarettes to pay for 100% of state liability insurance for surgeons, family practice doctors who deliver babies, and for OB-GYNs. However, doctors still have the other portion of their malpractice bills to pay. The state is working with courts to create more regulations and define reasonable parameters around jury awards. In 1 year, the amount of the awards has gone down, butit will take time for malpractice insurance rates to follow course.

This past year, Medicaid (MA) has lost $458 million from the federal government. This decline in funding will only get worse. There is a scheduled $60 billion cut in MA funding over the next ten years. We know that a woman and child on MA average $2,300 in care a year, while a senior citizen in a nursing home costs $23,000 a year in care. In Pennsylvania, the number of older citizens is growing, draining resources from other recipients of MA. The state has decided to put a cap on the number of doctor’s visits and hospitalizations that that MA will cover so that PA will not have to remove anyone from the program. These caps do not apply to pregnant women.

So what can be done? The first goal should be to get more women to run for political office. Women only comprise 12% of the Pennsylvania legislature.

Question and Answer
The audience engaged in a question and answer period. Some issues that came up:
     • Panelists discussed hospital closures as a result of market forces. Is anyone asking the question: did
       the right hospitals close? What was the planning process for the closures? Hospitals are now competing   
       not to deliver babies.

Question and Answer

     • No one competes to serve patients who cannot pay. We need to devise

       better incentives to serve the uninsured.
     • How do we make decisions regarding access to basic healthcare?
     • Who will provide health insurance to undocumented individuals and families?

The session ended with 16 Roundtable Discussions that provided all attendees an opportunity to engage further with the material and let their voices be heard.

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