Neonatal mortalityOne of the things that I have been able to do as an academic “Family Doc” is to continue to participate in the deliver of babies. The word obstetrics is from the Latin obstare which means “to stand by”. That is what I did last night, stand by for a complicated laboring patient who ended up having a sunrise (5:30 am) delivery. By my calculations I have either delivered or supervised the delivery by Family Medicine residents of over 1000 babies. I am struck by how deliveries at “teaching hospitals” have changed since I was a student at Charity Hospital in New Orleans. Medicaid required states to pay for prenatal care beginning in the mid 1990’s. Given a “public option”, many people are happy to use SOBRA Medicaid to pay for their pregnancy care (although in fairness, they don’t have any out-of-pocket expense) and many companies are content to have at least some of their maternity care covered via”the public option” when their employees can’t afford the high deductible insurance.

The stigma attached to being on “public assistance” for maternity care is gone. Many hospitals in Mobile are more than happy to take maternity Medicaid. We have had to compete for these patients and so we deliver babies at a very a nice facility (USA Children’s and Women’s Hospital) with birthing rooms, televisions, and lots of stuff that looks nice and makes patients want to come back. This is in contrast to my memories of Charity, with its open bay wards, communal laboring patients, and lack of involvement (in my memory) of the teaching faculty in the daily management of the patients.

Neonatal mortality has been reduced in the United States from 4/100 births in 1940 to 0.6/100 today. This correlates with the inclusion of maternity care in insurance policies and the growth of Medicaid as a viable payor for maternity care providers. Unfortunately, even for pregnancy care, access is not universal.  There are still great disparities in outcomes that are associated with the race of the mother in this country, almost certainly due to differences in access to healthcare. Mortality and morbidity correlates with state of origin. In Alabama  the current rate is 1.1/100 births, probably reflective of access and underlying conditions. 

Although changes in infant mortality can be attributed to other things as well as access to the health care system, it is clear that improvements in maternity care correlate with the reduction of the use of cash for childbirth and the development of this  public/private partnership, however dysfunctional it may be. When I was in medical school in 1985, prenatal care and a comfortable well attended delivery were clearly luxuries.I have attended this healthcare system during the transformation.  What we need to be discussing is which components of the care work and how to deliver them more efficiently. Instead, we have Senator Kyl who wishes not to pay for anyone else’s childbirth, no matter what.   Why are we as a country even having this discussion?

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