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Sunday
Nov272011

Better Risk Counseling Tends to Lower Procedure Utilization

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In case you’re not following the recent round of articles about the National Health Service’s new guidelines about cesareans, here’s a quick round-up.

A tried and true tactic used in the British media (especially in The Daily Fail Daily Mail) is to attempt to provoke shock and awe about women who actually—gasp!—want a cesarean.  It is apparent that the discussion has less to do about method of delivery than it does about trying to lure readers into debating one of the pervasive anti-feminist narratives of the modern Western woman,  i.e., she is selfish/lazy/unwilling to mother properly/unwilling to EVEN USE HER VAGINA TO GIVE BIRTH! And can you believe she might even go back to work in six weeks? WHO WILL FIX MY SUPPER? For the U.S. equivalent, turn on Fox News.

 

The balanced coverage:

Women can choose Caesarean birth [BBC, November 22, 2011]

NHS caesarean guidelines aim to push down demand for procedure: Guidance from Nice says while no woman should be refused a caesarean, proper information will drive surgery rate down [The Guardian, November 22, 2011]

 

A few of the many that apparently didn’t pay attention to the press release:

Caesareans will be offered to women in fear of labour amid concerns some are so afraid they seek abortion [Daily Mail, November 23, 2011]

Women to gain right to have planned Caesareans on NHS: Changes could lead to large and costly rise in numbers of women demanding the procedure [The Independent, November 27, 2011]

Caesareans to be offered to all amid fears over midwife shortages: Caesareans are to be offered to all pregnant women who ask for them, new guidelines state, amid concerns that some are too scared to give birth naturally on Britain’s overstretched labour wards. [The Telegraph, November 27, 2011]

 

 

The interview with National Institute for Health and Clinical Excellence (Nice) appeared in The Guardian article listed above clarified the NHS’s actual guidelines and rationale. They state that the goal is to ensure that no woman who wants a cesarean should be turned down, yet should receive proper counseling as to the risks of the surgery.

No woman who wants a caesarean should be refused one, but if women have the risks of surgery explained to them, the numbers should fall, according to fresh NHS guidance on childbirth.

The National Institute for Health and Clinical Excellence (Nice) has tried to deny speculation in the media that the new guidelines meant women would be entitled to a caesarean on demand, but the implication remains that nobody should be turned down.

Nice said most women would choose a vaginal delivery if they received proper information, and its guidelines committee said they did not recognise the concept of women choosing a caesarean because they were “too posh to push”.

Most women who asked for a caesarean had either physical or mental health issues that made them unable or unwilling to try ordinary delivery, they said.

The phrase “too posh to push” was “something the media created”, said committee member Nina Khazaezadeh, a consultant midwife at St Thomas’ hospital.

Once women had a full discussion of the risks and benefits with health professionals, “they want to opt for the safest option. A lot of the anxiety is related to lack of information and lack of knowledge,” she said.

 

The concept that informed choice will actually have an effect of lowering the rate of procedure utilization isn’t unique to Nice and can be found elsewhere, such as on the Dartmouth Atlas of Health Care site.

A recent study reported that almost three-quarters of Americans say they have declined interventions that were recommended by their physicians, because they thought that it was unnecessary or the benefits did not outweigh the risks or side effects. Other studies have confirmed that informed patients want much less surgery, on average, than surgeons are inclined to perform. Making patients aware of the risks and trade-offs associated with treatment choices is one good way of reducing demand for such things as hospital admissions, redundant or unnecessary testing, and surgery when there are other options. Because physicians are reimbursed for activities, the system encourages them to do more. Paying physicians to spend more time advising patients about treatment alternatives (for example, lifestyle changes and medications, rather than bypass surgery), without penalizing them economically for doing less, is another important strategy for reducing utilization. [Emphases mine]

 

It will be interesting to watch rates in the UK over the next few years and hopefully the NHS has a means to track data on whether cesareans are requested so that causation can be verified (or not). How these guidelines actually play out in the provider-patient relationship is always a different story, but my hope is that the new guidelines represent a step toward making preference-sensitive care and adequate risks-benefits counseling the norm for pregnant patients.

 

 

 

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Reader Comments (15)

My first reaction to this is that it is utterly tragic that there are women - even a small number of women - who are so mortally afraid of labor and birth that they would request serious surgery instead.

My second reaction is - wait a second. Isn't the NHS chronically underfunded and currently facing a financial sustainability crisis? This is their response - to underwrite more expensive elective cesareans? I know there would be women whose fear of birth is so severe that it could actually be deemed pathological, and that that could be the medical indication for a cesarean that it otherwise not medically indicated at all.

But if it is a procedure supported by the NHS, do we really believe that elective cesareans will be presented only as a last resort after thorough counseling for a very few, desperate women? When there are so many other reasons having to do with convenience that OBs recommend cesarean currently?

I think part of my issue with this is the constant rhetoric of "choice" that accompanies debates about birth. I am a birth doula and hope to be entering nurse-midwifery school shortly - in other words, I'm fully on the side of supporting women in their birth choices. But at the level of a healthcare system, policy choices need to be made that encourage both population health and the financial sustainability of the system (I would be referring to some totally fictional, ideal system that certainly doesn't exist in the US at the moment). That means that, assuming there isn't endless money in the system, expensive procedures that are not medically necessary should be actively discouraged - including elective cesarean. I realize that means that women's choices would not be the final word - i.e. giving birth by elective cesarean and having it covered by the NHS wouldn't be a "right", and some women demanding elective c-sections (are there really so many?!) wouldn't be able to have them.

Am I missing something here? Is birth in the UK really so different from the US? Or do we really think that hordes of women would suddenly start demanding cesareans in the UK with no medical indication when that hasn't been the case on this side of the Atlantic?

November 30, 2011 | Unregistered CommenterBird

So you're "fully on the side of supporting women in their birth choices" except not really, right?

November 30, 2011 | Unregistered CommenterYttrbia

Jeez, snarky much?

I am on the side of supporting women in their birth choices, but I recognize that a public healthcare system puts limits on choices in order to serve the greatest number of people, to the greatest extent, with the best care possible (hopefully...). I wish that the US had a national healthcare system, although in my dreams, this is one that would function better than the NHS. What this would mean is that you should have choices in care covered under such a system - not just for birth, but for all healthcare services - but not limitless choices if they are not supported by medical evidence as this strains a system meant to serve everyone. Should your cesarean be fully covered when it is medically indicated? Absolutely. Should it be covered when it isn't medically indicated? No. I recognize that that puts a limit on women's choices, and it means that I disagree with the statement quoted above that "No woman who wants a caesarean should be refused one." We have focused so much energy on "choice" in birth - and for good reason, since the one-size-fits all approach often used in hospital settings can be both dangerous and degrading - that we run the risk of championing it even when it amounts to asking an OB to perform an unnecessarily dangerous procedure.

On that point, and strictly from a philosophical point of view, I also think there ought to be an issue with physician ethics here. If I walked into an ER with a minorly infected big toenail and asked them to please amputate my whole foot to deal with it, they would probably refuse. Even if I offered to pay out of pocket for this surgery they would probably refuse - because it is medically unnecessary, more expensive than what is needed, and would carry risks larger than simply treating my infection. (I probably wouldn't be given "choice" in the matter at all, and wouldn't be able successfully to demand surgery.) So why do OBs agree to perform elective cesareans when exactly the same is true?

Again, I think this whole argument is largely a philosophical one because, despite how often articles crop up about elective cesarean (OMG THOSE LAZY SELFISH WOMENZ) the proportion of women who do choose cesarean with no medical indication is very small.

November 30, 2011 | Unregistered CommenterBird

It's hard not to be snarky when you hear another person proclaim that she advocates women's choices when she really only means those choices that align with her value system.

Honestly, equating maternal choice c-sections with amputating a healthy appendage is absurd. The baby has to be delivered in some fashion- either vaginally or by c-section, and choosing one over the other is just trading one set of risks for another. People choose between more and less-invasive medical treatments and procedures all the time. It's called patient autonomy. Why should we deny it to childbearing women?

The financial rationing aspect of your reply makes me ill. Should we constrain everyone's medical options to the least expensive thing available? It's definitely not a system I'd care to be a part of.

Anyway, your argument rests on the premise that c-sections are more expensive. On a personal note, my (forced) natural delivery and subsequent surgical repair cost a great deal more than a simple c-section would have-- financially, and in terms of suffering and medical risk. When people factor in the long-term costs of complications of vaginal birth the cost savings disappear. It's a case of penny-wise, pound foolish mixed with bad ethics and a bit of misogyny.

December 1, 2011 | Unregistered CommenterYttrbia

You're right, my value system (and political philosophy) does play into this. I favor a healthcare system that covers everyone and that everyone pays into. People who don't favor such a system would come to different conclusions about choice in healthcare.

You can pull the misogyny card all you like, but clearly you're not really looking at my argument. I happen to think that pregnancy and childbirth are utterly unique experiences from the perspective of the individual woman and her family - they are not "medical processes", but they are physiological processes that call for healthcare services to ensure healthy outcomes. They are deeply personal and significant family and social events.

From the perspective of a healthcare system, however, they are not exactly unique and therefore comparing them to the toe infection situation is not inappropriate. From a system perspective, both require clinical decisions about what course of care is appropriate, factoring in patient/client desires (what does the patient want), clinical capacity (what treatment options exist at all), treatment cost, and ethics (what are the risks and benefits of treatment options?) This cold calculus may make you ill - but the current medical system that we have in the US makes most people ill. Trotting out "rationing" (and, just to head this off at the pass, the old favorite "death panels") is simple fear-mongering and does not acknowledge the fact that well-funded national healthcare systems in developed countries like the US tend to get better health outcomes, for more people, for less money than we are currently spending in the US.

You might not want to partake in a system in which there are any limits on choice - but if such a system would mean that everyone in the country could receive adequate healthcare, both for birth and for medical events requiring care, I would want to partake in such a system. Many would.

You are correct that putting limitations on elective cesarean is based on the assumption that they are more expensive - but where exactly have you seen evidence to the contrary? I am deeply sorry to hear about your traumatic birth experience - I can't imagine the physical and emotional pain of it. However, all of the evidence that I have seen shows that cesareans, as a rule, are more expensive than vaginal births, and that includes factoring in follow up care (since women who have had cesareans tend to have higher rates of readmission to the hospital, surgical site infections, etc.) I have not seen evidence anywhere that, at the population level, the greater initial financial costs of cesarean are equaled by the long-term costs of caring for women who have had vaginal births.

All of the evidence I have seen also shows that performing a cesarean with no medical indication is riskier for both the mother and the baby than a (low intervention) vaginal birth - it isn't simply "trading one set of risks for another", it is trading a smaller set of risks for a larger set, which I think is something that both clinicians and a healthcare system in general should actively discourage.

Again, I am so sorry that your birth experience was complicated and painful.

December 1, 2011 | Unregistered CommenterBirth

Woops - entered my author name as Birth instead of Bird on that last post...clearly have the topic on the brain. :)

December 1, 2011 | Unregistered CommenterBird

I don't believe I made any claims about what sort of health care system we should have in the US. Nor did I mention death panels. I simply said that I wouldn't want to be part of a healthcare system that limits choice to the cheapest alternative. I think it's unethical and backward, and frankly, when imposed only on choices that apply to women specifically, sexist.

And it IS trading one set of risks for another. It is not the case that planned vaginal birth unequivocally results in better outcomes in all areas. Planned c-sections have advantages over planned vaginal births in some areas and vice versa. Neither is risk-free. There are individual differences to consider as well, in terms of both preferences and value systems but also in terms of absolute risk. These are decisions that should be left to individual women and their health care providers to decide in the context of informed consent.

If you genuinely support women's choices and autonomy in childbirth, please stop trying to impose your value system on women who don't share it and may actually be harmed by it.

December 1, 2011 | Unregistered CommenterYttrbia

Yttrbia,

In a perfect world, you would be correct, but we do not live in a perfect world. What Bird is arguing is on the practical side of things, which is the side of things that I stay on. A public health care system has a limited reach, because even if the medical industry is reigned in so that some things cost less, it is still a cost-heavy process. Public funds are not endless, and when designing a real system that may exist in the real world instead of utopia, decisions need to be made.

You deem it backward to limit choices to the cheapest, which for one, is a view on Bird's comments that totally lacks nuance. But I'll bite anyway. If it's backward to limit choices to the cheapest regarding, birth, where does it end? Currently, those on Medicaid for dental care often don't have GA paid for pretty traumatic procedures (so you get to be awake getting your wisdom teeth removed), and in general nothing is paid for to save teeth other than fillings. If the nerve tissue in the tooth becomes corrupted, you get that tooth pulled, you will not get a root canal. So you would like women in a public health care system to have full choice of birth options, regardless of cost, because you deem that to be modern. I personally find it rather backward that the poor can only afford to lose their teeth as they age. Maybe someone else finds it rather backward that health food isn't accessible to all children. The possibilities for spending public money are endless, but the pool of public money is not endless, so in the end priorities need to be evaluated and decisions need to be made.

Because you can't reconcile the fact that Bird may really truly wish for full autonomy and options for women, but also understand that in a public health system compromises have to be made, to me says that you are a zealot that can't compromise or negotiate anything even remotely realizable. And in the end, you can yell about values systems all you want, Bird was talking about a *public* health system. Public means us, it means all of us, and in the end, any public system is going to do its best to serve all of the public the best that it can, and to that end any individual's precise values system means very little.

Am I also anti-women as well, Yttrbia?

December 1, 2011 | Unregistered CommenterKala

Well then perhaps we're talking about two different things. I'm talking about how what procedures should be encouraged or discouraged in a national healthcare system, since the articles in the original post are regarding changes in the NHS. This led me to consider what an actual healthcare system would look like in the US (as opposed to what we currently have, which is healthcare provided by numerous fragmented parties, insured or uninsured to differing degrees by different parties), although this is, of course, entirely speculative.

Acknowledging my limited understanding, I think it's still fair for me to say that the NHS isn't about "limit[ing] choice to the cheapest alternative", nor is that what I was proposing in the US. What I was proposing was a system that does allow for patient choice, but it limits fully covered choices to those based on achieving the best outcomes given the best evidence we currently have - which would not necessarily include paying for cesareans for women for whom it is not medically indicated. This is in no way sexist, as national healthcare systems must make such considerations for all medical procedures, for all individuals, female or not, pregnant or not. We're simply discussing the case of birth, which yes, pertains only to women.

So there we have it: in a hypothetical country in which all individuals are meant to be covered by a national healthcare system (like the UK), with the aim of providing the best care possible for the greatest number of people in a financially sustainable way, I would not be in favor of this system paying for unlimited choices for women in childbirth when those choices are not supported by sturdy medical evidence. Rather, I would support a system that provides full coverage for those healthcare choices that are supported by sturdy evidence showing statistically that they tend to achieve the healthiest outcomes for women and babies (allowing of course for nuanced treatment based on myriad individual patient circumstances). Neither am I in favor of such a system paying for patients in general to have unlimited choices in all of their care and treatment with no supporting evidence. To wit: if your toe is infected and can be treated simply and effectively with antibiotics, the general policy should be that the system pays for you to get antibiotics even if you're demanding the amputation of your foot. Does this limit "patient autonomy" and "patient choice"? Yes, it does - but it does this so that there is enough money in the system for everyone who actually needs to have their foot amputated to have this surgery covered. I think that is a reasonable trade-off at the system level, even if it upsets the person with the infected toe.

So I suppose we just have a philosophical disagreement. For me, there is such a thing as supporting women's choices and autonomy in childbirth, while acknowledging the reality that these choices do not take place in a vacuum - they are guided by healthcare policies. Given the fact that most people are, unfortunately, not especially healthcare literate (and even if they are, individuals shouldn't feel that they have to to know more than their healthcare providers just to protect themselves against mistreatment) - my hope would be that these policies are anchored in the highest quality evidence, designed to achieve the most good for the greatest number.

December 1, 2011 | Unregistered CommenterBird

I'm not sure what you're advocating, Kala. Should we adopt a universal payer system that covers everyone for only the most basic treatments? I doubt such a thing would be desirable or ethical. How do you decide which treatments should be covered? Do you pay for mental health counseling, drug addiction treatment, weight-loss surgery, smoking cessation aids? Do people with auto-immune disorders get the new, expensive biologic agents or should they make do with the less-effective but cheaper corticosteroids? Insulin pumps? Organ transplants? There are endless examples of choices in medicine that are complicated in terms of ethics and economy. I think it's reasonable to think that the main goals of any health care system should encompass both respect for patient autonomy (as seen here in the NICE guideline change) AND an effort to provide the best care possible.

Is there some reason that the burden of cost-cutting should be placed on the backs of pregnant women exclusively? I can't really think of any besides the desire to force your philosophical preferences on everyone or simple misogyny.

And good grief, an elective c-section is not equivalent to amputating a healthy appendage! I would love to see more studies on the risk:benefit ratio of CDMR to planned vaginal delivery, but the few that do exist suggest that for the baby it is comparable or even favorable, and the risks to the mother are small, and when weighed with the risks (both short and long term) of vaginal birth, the risks are really quite comparable. It's a reasonable choice for some individuals and should be respected as such.

December 1, 2011 | Unregistered CommenterYttrbia
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