The United States finds itself in a peculiar position.  Despite the fact that we live in a prosperous and powerful nation, we lag behind many other developed nations in terms of many health related outcomes.  Perhaps nowhere is this fact more evident than in the areas of premature birth and infant mortality.  The United States now ranks 33rd in terms of infant mortality. 

We are nowhere close to the leaders in this area; countries like Singapore, Japan and Sweden; and we even have a higher infant mortality than countries like Slovenia, Cuba and New Zeland .

As I see it, the differences between our outcomes and those of other nations can be blamed on either:

• differences in patients, 
• differences in physicians or 
• differences in the nature of our health care systems.  

A recent report in the New York Times  highlights the fact that all three are involved and that in order to improve infant mortality in the United States, a much more broad-based approach needs to be adopted than those currently proposed.

The NYT article by Denise Grady details a recent report from the CDC  that high rates of premature birth are a principle reason that United States has higher infant mortality than many other countries.  

The statistical analysis between the US and Sweden is sobering and makes the nature of the problem clear:

• In Sweden, 6.3 percent of births are premature, compared with 12.4 percent in the United States
• In Sweden 2.4 babies per 1000 will die in the first year of life.  In the United States the number is 6.9 per 1000.

Is it a worthwhile goal to attempt to improve infant mortality?  

The report indicates that “If the United States could match Sweden’s prematurity rate, nearly 8,000 infant deaths would be averted each year, and the U.S. infant mortality rate would be one-third lower.”

The problem of premature birth and infant death in the US is multifactorial; and no single intervention will change the trend.

One problem mentioned in the article is the fact that the increasing use of labor induction and cesarean delivery is contributing to an increase in so called “late preterm birth” (babies born between 34 and 37 weeks) and this trend is contributing to prematurity levels as well as infant morbidity and mortality.

To be clear, there are many cases where an early delivery is necessary (and indeed life saving), but there is growing concern that some physicians are recommending early delivery where a clear medical need does not exist.  It is also clear that (in some cases) patients are requesting early deliveries which result in some of the problems previously stated.

Dr. Marian F. MacDorman, a statistician at the National Center for Health Statistics was the author of the study   and stated that  ”Fifteen or 20 years ago, if a woman had high blood pressure or diabetes, she would be put in the hospital, and they would try to wait it out. It was called expectant management. Now I think there’s more of a tendency to take the baby out early if there’s any question at all.”  

Those comments point to what I feel is a critical problem in the field of perinatal medicine.  That of risk appreciation and risk tolerance.  There will always be some level of risk in the process of giving birth; however, more and more both physicians and patients are so risk averse that they are in many cases prematurely delivering a baby to avoid one risk and ending up with another risk entirely.  Defensive deliveries where a physician decides to deliver a baby early due to the fear of a lawsuit have a great deal to do with the trend in late preterm birth.  Tort reform may change the motivation of some physicians to act in this manner; however, I think that there needs to be a change in the culture of medicine and the expectations of patients to really make headway on this front.

Perhaps the larger issue that we as a society should consider is what I have called the “over-medicalized” the pregnancy.  The fact that patients are being delivered early without a clearly defined medical reason just highlights the point that adverse outcomes can result not only from the absence of an intervention, but the presence of the wrong interventions.  I’m sure many of my colleagues will disagree with me on this.  (And gee whiz, it would also appear that I am undercutting my own business model as a “high-risk” pregnancy doctor.)   

But I think we are at a point where we cannot ignore the facts. 

Home births have been shown to have outcomes that are similar to or better than hospital births IN APPROPRIATELY SELECTED PATIENTS.

Low tech interventions such as group prenatal care  that give patients a more participatory role in the birth process also have been shown to reduce premature births.

The common thread is limiting medical interventions to the subset of patients who would benefit most.

As we strive to reform health care and improve infant outcomes, a multi-pronged approach seems not only reasonable but necessary.  As physicians and patients we need to understand that more is not always better.  Sometimes more is just more; and sometimes more is worse.  

Posted via web from onyeije’s posterous