Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and

There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.

This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says

It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.

Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say

In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10^th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 1 (of 4 parts)

This is part one of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

“The dream of reason did not take power into account”.

--Paul Starr, "The Social Transformation of American Medicine", 1982

In 2008, the British Healthcare Commission began an investigation into conditions at Stafford Hospital, run by the Mid-Staffordshire Health Trust.[1]The investigation was prompted by patient complaints and a higher-than-expected death rate, and it and subsequent[2]investigations uncovered a pattern of both poor quality care and cover-ups by those running the hospital. It became a major national scandal. In 2014, whistleblowers began to reveal the extent of problems in the Phoenix Veterans Administration system, with long delays for appointments, inadequate care, and even excess deaths. The investigation revealed enormous cuts in services, as well as efforts to cover up the problems, similar to those in Stafford. Moreover, it turned out that the problem was far more extensive across the VA than just Phoenix.

These two events are discussed by M. Gregg Bloche in his NEJM Perspective “Scandal as a Sentinel Event — Recognizing Hidden Cost–Quality Trade-offs”[3]. The details of the two scandals differ, as do the health systems of the two countries in which they occurred, but there are disturbing similarities.

“As with the VA scandal,” Bloche writes, talking about Staffordshire, “politicians blamed individual perpetrators and one another, and the prevailing narrative highlighted lapses of character and culture…In both cases, performance standards often proved incompatible with resource constraints….The fakery was discovered, and perpetrators were punished. But the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged.”

So, while more rigorous standards were being set for performance, budgets were being cut. These cuts made it difficult or impossible to meet those standards, and administrators in both systems covered up the problems. They lied about their compliance with the standards -- and, not coincidentally, often got financial bonuses for doing so (or at least got to keep their jobs). In addition to the probably unnecessary deaths, outcomes were more generally poor care for all patients. In the British case, the excess deaths were pretty well documented, as were the stories of patients lying in urine and excrement, inadequate food, and unavailable nursing care. In the US, at the VA, proving excess deaths was more difficult, but excessively long waits, particularly for specialty services, may well have contributed to unnecessary or premature mortality, and falsifications by the administrators were very clear.

In both cases, heads rolled – local administrators, the head of the Mid-Staffordshire NHS Trust, and in the US eventually the head of the VA.  The politicians, in the US Congress and the British Parliament, who had been responsible for the funding cuts in the first place, took no responsibility and indeed used these scandals to act in a self-righteous manner, denouncing “those responsible”, while being clear that this did not include themselves. Nowhere in the discourse in the media are the budget constraints and cutbacks acknowledged as a major cause of the problem.

And, yet, the politicians were surely responsible, because it was the budget cuts that they imposed, along with the potential they built in to these systems for financial gain on the part of those directly tasked with running the operations, that led to these problems, certainly along with the collusion of the people directly in charge. The process has had two steps  – first, we are going to cut your funding and you are going to have to figure out how to cut in a way that doesn’t, at least obviously and in a manner that reflects on us, cut services. Second, we are going to tie rewards – institutional and personal (direct financial bonuses, or at least keeping your jobs) – to the degree that you can cut costs. We are also going, to a greater or lesser degree, “privatize” operations on the assumption that this will, with the motivation of profit, increase the efficiency (and lower the cost). And if we cannot privatize them, we will use “motivators” characteristic of private enterprise – again see financial bonuses. And now a right-wing group of Koch-funded consultants and legislators is creating a proposal to essentially privatize the VHA, covered by Suzanne Gordon,

“The proposal they have crafted is an exercise in incoherence, denial, and magical thinking. he group believes that private sector hospitals would be willing and able to recreate VHA Centers of Excellence and other programs like the San Francisco VAHCS’s Center of Excellence in Epilepsy or Primary Care Education or Palo Alto’s polytrauma, blind or spinal cord injury rehabilitation programs. It also believes the private sector could fulfill the VHA’s research and teaching missions. As one San Francisco VAHCS researcher told me, “Can you see my eyes rolling?”’ http://suzannecgordon.com/the-plot-thickens/

It is of more than passing interest that both of these events occurred in government agencies that were established to provide necessary care to people. In Britain, the National Health Service, established in 1948 to expand upon the National Health Insurance program that had existed since prior to WW I, is enormously popular because it provides care to everyone. Let’s think about this for a minute. 1948 was soon after the war. Britain, as most of Europe (but not the US) was in shambles, its population of young men decimated, its economy and industrial capacity largely destroyed, its streets covered with rubble from the Blitz (think the street scenes of East London in Call the Midwife from over a decade later), and the last thing that they had was “extra money”.

 
 But the National Health Service was established, not as largesse in a time of plenty, but as a way of meeting the needs of the British people. In the US, a different story unfolded; with its industrial capacity intact and the need to shift from war to consumer production, the demand for labor exceeded the number of workers. Prevented from increasing wages because of wage and price controls, large companies found offering health insurance (non-taxable) a significant inducement, and found common cause with labor unions who could then offer these benefits to their members; a win-win that led to the employer-based health system that has characterized the US since.

In Britain, the Mid-Staffordshire scandal broke under a Labor government, but the seeds were sown when the Conservatives were in control. Recognizing that the NHS was far too popular to be dismantled, the Tories, seeking to emulate the US, both cut funding and established “NHS Foundation Trusts”, like Mid-Staffordshire, which were in a sense semi-privatized and incented to save money by being offered an opportunity to keep some of the savings, which could be used both for reinvestment in the hospitals and health system and to bonus those in charge. In the US, our services to veterans have almost never (as documented by Bloche) kept up with our rhetoric about the heroism of the men and women who serve in our military, and the VA scandal was tightly linked to cuts in funding. Indeed, some of the “solutions” offered by the same Congressmen who were responsible for the cuts involved privatization; this is often proposed as a solution to not having enough money, and almost never works, at least if the goal is improving quality.

As Suzanne Gordon says in her piece on the growing efforts in Washington to privatize the VA:

‘In their document, the Strawmen [the group working on this] justify their position on total privatization by pointing to the fact that the VHA is having trouble hiring new recruits to fill many staff vacancies because of the “stigma” attached to working at the VHA.  They also argue that the current VHA workforce suffers from “poor morale” and a “culture of fear.” Of course, VHA management practices could be significantly improved.  But if there is now a “stigma” attached to working at the VHA, a “culture of fear” within it, or demoralization among its current employees, that is, in great part, due to the bashing conservatives have unleashed in the media and Congress.’

But we’ll get back to that.

(to be continued)

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[1] http://webarchive.nationalarchives.gov.uk/20110504135228/http://www.cqc.org.uk/_db/_documents/Investigation_into_Mid_Staffordshire_NHS_Foundation_Trust.pdf

[2] http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report

[3] N Engl J Med 374;11 nejm.org March 17, 2016, pp 1001-3