I read with great anticipation the Viewpoint in the June 2019 issue of Managed Care titled “U.S. Infant and Maternal Mortality Rates: Shamefully (and Unnecessarily) Bad and Getting Worse.” The author, François de Brantes, offered three suggestions: make participation mandatory for seven states that chose not to participate in perinatal quality collaboratives (PQCs); institute innovative payment systems because the author submitted that current payment structures are the primary determinant of unnecessary and potentially harmful C-sections; and, lastly, that employers team up with the March of Dimes to educate mothers, engage communities, and reform payment. I believe the combination of all of these would have very little impact on maternal mortality or preterm birth. Certainly, no proof exists demonstrating any potential outcome improvement with their implementation.
Perhaps de Brantes could have looked to California to identify the clinical interventions employed in the state and identify opportunities to replicate them in other states. Hemorrhage and eclampsia are the leading causes of maternal death. Spoiler alert: Clinical protocols for objectively measuring blood loss during labor and sequential blood pressure and urine protein measurements made the difference in California. Not participation in PQCs, new payment structures, or patient education!
Researchers suspect social behaviors such as smoking, poor nutrition, sexually transmitted diseases, multiple sexual partners, and drug and alcohol use impact the prematurity rate. These are not easily changed. Clinical interventions such as 17 Alpha-Hydroxyprogesterone Caproate (17P) for the prevention of preterm labor in patients with a prior preterm birth, which was the subject of a study published in the October 2005 issue of Managed Care, is proven to prevent preterm birth in a select population. Unfortunately, this therapy is not used for all appropriate candidates, so its full impact is not yet realized. Additionally, daily low-dose aspirin in patients with preeclampsia in a prior pregnancy is proven to reduce medically indicated preterm birth, and it is estimated that only 20% of therapeutic candidates receive the intervention.
De Brantes’s last two paragraphs claim the problem of U.S. infant and maternal mortality occurs because of “payment systems that can end up rewarding physicians and facilities for bad outcomes and that allow them to extract the highest rent possible from all other economic actors.” This bombastic statement is completely unsupported by evidence and is inflammatory.
Without question, payment reform is needed to curb spending and shape behavior in the U.S. health care system. Payment reform will not solve the complex problem of preterm birth or maternal mortality; they are not easily and completely solvable problems. To state that they are is irresponsible, demonstrates lack of understanding of the true nature of the problems, and is utterly simplistic.
James P. Reichmann
Retired president of the women’s and children’s health division