The IRS has ruled that breast pumps and supplies that assist in lactation do quality as medical care and are therefore deductible medical expenses that can be paid for through Flexible Spending Accounts (FSAs) and other medical spending accounts.

The American Academy of Pediatrics had previously requested that the IRS rule that these supplies be added to the list of qualifying FSA items, but received a denial stating that breastfeeding did not constitute medical care. The new ruling does not decide that breastfeeding is medical care of an infant, but rules that the supplies are medical because “they are for the purpose of affecting a structure or function of the body of the lactating woman.” The AAP has applauded the change as “an important victory for the health of women and children across the country by making breastfeeding a more practical option for new and working mothers.”

In other news, the Associated Press has covered the issue of access to nitrous oxide for women in labor. The piece explains that some institutions (including my own) are currently working to make nitrous oxide an option; it’s commonly available to laboring women in some other countries. The item notes at the end that “the federal Agency for Healthcare Research and Quality is reviewing the effectiveness and safety of nitrous oxide compared to other pain relief methods” – I’m on the team for this project at work, so we’ll be sure to let you know as soon as that report is available.

Escrito por Raquel; Traducido por Ema Rosero y el Rev. Daniel Velez-Rivera
del orginial en inglés Jan. 26, 2011

El grupo Leapfrog es una organización empresarial que vela por los intereses del empleador y examina la seguridad y calidad de servicios de hospitales en los Estados Unidos.  Esta organización anualmente distribuye los resultados de encuestas para determinar los “mejores hospitales” en el país. En el día de hoy Leapfrog publicó data sobre la tasa de partos elegidos pretérmino por cesárea e inducciones realizados sin urgencia médica en hospitales estadounidenses.

Como indican los apuntes de periodismo y otros medios de comunicación de Leapfrog, ACOG y otras organizaciones repudian la inducción o cesárea elegida previo a las 39 semanas de gestación para reducir las posibles complicaciones para madres y bebés. La agencia de acreditación de hospitales hospitales “TheJointCommission” también ha estado prestando atención a este asunto.

Se les preguntó a los hospitales sobre el número total de nacimientos y el número total de nacimientos inducidos o por cesárea sin urgencia médica que acontecieron entre las 37 y las 39 semanas de gestación.  De los 773 hospitales que respondieron las tasas oscilaron entre menos de 5% a más de 40%, y variaron ampliamente entre diferentes estados y ciudades estadounidenses.  El grupo Leapfrog estableció una tasa meta de 12% y clasificó a los hospitales como mejores o peores a partir de esa tasa.  Según las respuestas obtenidas la mitad de los hospitales satisfizo esta meta. No es evidente cómo se estableció el objetivo, pero sin embargo el Grupo indica que espera disminuir la tasa al 5% en el 2011.

Los resultados de la encuesta aparecen por estado en la página.

No todos los hospitales respondieron y a mí me gustaría obtener más detalles sobre la metodología de la encuesta. No obstante, esta data puede proveer a mujeres embarazadas un punto de partida para escoger el hospital adonde dar a luz y también para las personas interesadas en reducir el número de partos elegidos pretérmino y los riesgos asociados con éstos.

El Grupo Leapfrog está ofreciendo dos seminarios en internet tipo webinar para profesionales de salud auspiciado por el Director Científico y Director Médico del March of Dimes. El enfoque será cómo utilizar la caja de herramientas de las 39 semanas (39-week toolkit) desarrollado por la “March of Dimes” y sus colaboradores. Estos seminarios son gratuitos el 15 de febrero entre las 12 del mediodía y la una de la tarde hora (ET).

Con motivo de la publicación de este informe la organización ChildbirthConnection ha publicado una nueva sección sobre inducción de parto en su página web.

The Leapfrog Group, an employer-oriented organization that examines the safety and quality of U.S. hospitals and releases an annual “top hospitals” list, today released data on rates of early elective cesarean sections and inductions performed without a medical indication in U.S. hospitals.

As Leapfrog’s media advisory notes, ACOG and other organizations recommend against elective induction or cesarean prior to 39 weeks in order to minimize possible complications for women and their babies. Hospital accrediting organization the Joint Commission has also started paying attention to this issue.

Hospitals were asked about their total number of births and number of births where an elective induction or cesarean section without a medical indication happened between 37 and 39 weeks. From 773 responding hospitals, rates ranged from <5% to >40%, and varied widely within states and cities. The Group set a target rate of 12%, and classified hospitals as better or worse than that target – half of hospitals reportedly met this target. It is not readily apparent how this target was set, but the Group does state that it plans to lower the target to 5% for 2011.

Results from the survey are arranged by state at http://www.leapfroggroup.org/tooearlydeliveries#State. Not all hospitals responded, and I’d like to see more details about the survey methodology, but this data may provide a starting point for women choosing a hospital and those interested in working to reduce the rate of these early elective births and their associated harms.

The Leapfrog Group is holding two webinars for health care professionals, hosted by Leapfrog’s Senior Science Director the Medical Director of March of Dimes to focus and on the new 39-week toolkit developed by the March of Dimes and its partners. These webinars are being offered free of charge on February 15th from 12 noon to 1:00 p.m. ET and February 17th from 3:00 p.m. to 4:00 p.m. ET.

Related to the release of the report, Childbirth Connection has published a new section on induction of labor on its website.

The American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives have put out a call for papers for an upcoming issue of ACOG’s journal, Obstetrics & Gynecology. The call asks for contributions “describing successful and sustainable models of collaborative practice involving obstetrician-gynecologists and certified nurse-midwives/certified midwives.”

The call explains:

The impending maternity care workforce crisis necessitates focusing on best practices across the US; therefore, preference will be given to papers about successful collaborative practice and outcomes. Discussions of how physician and midwife collaborative practice models have affected maternity and women’s health care in both community and academic settings are being sought. Papers will be evaluated based on thoroughness of description, sustainability, level of influence on access to care, health disparities, vulnerable populations, clinical outcomes, education or research.

Top papers may win a prize and authors may be asked to present at upcoming conferences for both organizations. Papers must be coauthored by at least one ACOG Fellow and one ACNM member who is a Certified Nurse-Midwife/Certified Midwife. The deadline is February 1, 2011.

The CDC released its preliminary report on 2009 U.S. birth data this week, and the following finding is likely to be of interest to our readers:

The cesarean delivery rate rose to 32.9 percent in 2009, another record high.

This was a 2 percent increase over the previous year; the report indicates that the rate of cesarean is up nearly 60 percent since 1996. The increase was largest among non-Hispanic black women (up 3 percent), and women age 40 and over (half of all births in this group were by cesarean).

Preterm births declined for 2009, for the third year in a row. Other findings include a slight decline in the overall birth rate from 2008, a 6 percent decline in births to teenagers, and overall declines among every racial/ethnic category and almost every age group. Women age 40 to 44 were the only group whose birth rate increased in 2009, up 3 percent from 2008.

The report does not speculate as to the reasons for these decreases, but it’s hard not to wonder if economic conditions were a factor.

Last month, I posted that public comment was being solicited for an upcoming review of nitrous oxide for relief of labor pain. As a reminder, comments are being accepted until Dec 8, so submit yours here if you have any thoughts on the proposed questions to be examined in the review.

The public comment period has just opened on a second upcoming review that may be of interest to readers: Comparative Effectiveness of Interventions to Reduce Cesarean Births. If you have suggestions on the proposed questions that the review will try to answer or things the review team should be aware of, please submit your comment by December 29.

I’ll be involved to some extent with both of these topics at work; we appreciate your input!

by Nekose Wills | OBOS program assistant

The Coalition for Improving Maternity Services (CIMS) has started the Mother-Friendly Nurse Recognition Initiative, which aims to recognize nurses who are dedicated to using an evidence-based model of care to improve health outcomes of birthing women and their babies.

CIMS will confer recognition to nurses who provide maternity care services consistent with the 10 Steps of the Mother-Friendly Childbirth Initiative (pdf). These nurses keep the best interest of women and babies at the forefront while embracing the MCFI as their guiding philosophical approach to the care of birthing women.

This handy FAQ page explains the program’s goals and application process. The application is available here.

Given the vital role nurses play in patient care and satisfaction, we are glad that CIMS recognizes their importance as well as the purpose of evidence-based care, even when it is not the popular choice.

This week, the Illinois House of Representatives is expected to vote on the Home Birth Safety Act (SB 3712) to license certified professional midwives (CPMs).

Passage of the bill would allow CPMs to legally attend home births throughout the state. While approximately 800 babies are born at home in Illinois, only six out of 102 counties have legal, licensed home birth providers (CPMs, nurse midwives or doctors).

“As a result, families are resorting to giving birth at home unassisted (the national rate for this increased by 10% last year) or crossing the border to give birth in hotels in ‘legal’ states such as Wisconsin, or working with underground midwives,” reads a petition in favor of the bill.

There are 27 states that recognize direct-entry midwives, 25 through licensure, which is provided by the North American Registry of Midwives.

For the first time in 30 years, the bill made it out of a House committee in May, but passage is far from certain.

“It’s an uphill battle in the House,” Democratic State Rep. Robyn Gabel,the bill’s chief sponsor, told The New York Times earlier this year. Jessica Reaves writes:

That the bill has made it this far is testament to the midwifery community’s newfound political acumen and its first lobbyist, hired by the Coalition for Illinois Midwifery in 2006.

The bill’s opponents, including the American College of Obstetrics and Gynecology, the Illinois State Medical Society and the American Medical Association, argue that home births are inherently more dangerous than births in medically supervised settings. Also resisting the bill, though more quietly, are members of rural midwifery groups that have operated under the radar and off the grid for years, and would prefer to remain that way.

“We just don’t think home is a safe environment for delivery,” said Dr. Jacques Abramowicz, co-director of the Fetal and Neonatal Medicine Center at Rush University Medical Center and a Fellow of the American College of Obstetrics and Gynecology. “Childbirth is very dynamic, and it can be a very dangerous process. In the vast majority of cases, nothing happens. However, if an emergency occurs, it happens very fast — in two, three, four minutes.”

Rachel Dolan Wickersham, president of the Coalition for Illinois Midwifery and the vice president of the Illinois Council of Certified Professional Midwives, is the midwife groups’ lobbyist. She said she was frustrated by the bill’s opponents in the medical community.

“There’s just no room for negotiation,” Ms. Wickersham said. “It’s a turf battle. It’s about power and control. These women are going to have babies at home. There’s no question about that. Why would anyone want to keep the situation so that the person attending them has no regulated training or is afraid to transport them to a hospital in an emergency?”

Illinois Families for Midwives has put together information about the bill and is encouraging supporters to contact their representatives and, if possible, travel to Springfield on Wednesday.

In the health resource center at Our Bodies Ourselves, you’ll find a statement signed by dozens of physicians, midwives and women’s health advocates who support 1.) expanding options for hospital-based midwifery care (utilizing certified nurse midwives and certified midwives); and 2.) licensing and regulating certified professional midwives in order to make the option of home birth as safe as possible.

Many of you may already be familiar with the systematic and comparative effectiveness reviews produced by the Agency for Healthcare Research and Quality (AHRQ), such as these reviews of the available evidence for birth-related interventions such as labor induction, maternal request c-section, VBAC, and episiotomy.

Recently, AHRQ has become more active in soliciting public input to the review process, and today they posted for public comment the key questions and background materials for a review that will be conducted soon, Comparative Effectiveness of Nitrous Oxide for the Management of Labor Pain.

Nitrous oxide is commonly available to women for labor pain relief in many other countries, but is almost completely unavailable as an option for women in the United States. The comparative effectiveness review on this topic will examine the available evidence and look at specific questions such as its effectiveness, adverse effects, effects on women’s satisfaction with their birth experience and pain management, and health system factors influencing whether nitrous oxide is available to women who would like that option.

The public is invited to comment on this list of key questions to be addressed by the review, and can also review some background information describing the current use of nitrous oxide in the United States, the nature of the available literature, and the outcomes the review will examine.
Public comment is being accepted through December 8, 2010 via this online form; the site also provides a document to download and submit by mail if you prefer.

This project is of particular interest to me because of my work with the AHRQ Evidence-based Practice Center conducting this review. I have been involved with this topic in its preliminary stages by helping to examine the literature and writing up background information to inform the feasibility and potential impact of a full comparative effectiveness review. I will continue to be involved with the project team when the full review begins, and of course will update here when the review is completed and released.

For additional discussion of nitrous oxide for labor pain relief, please see our 2008 post with guest commentary from Judith Rooks, who has been advocating for expanded access to this choice for U.S. women.

AHRQ also accepts nominations for new review topics from the general public; the nitrous oxide topic itself was submitted by an anonymous consumer. To suggest a new review topic, visit http://www.effectivehealthcare.ahrq.gov/index.cfm/submit-a-suggestion-for-research/.

by Cory L. Richards | Guttmacher Institute

Rand Paul, a candidate for the U.S. Senate from Kentucky, caused a stir last week when he argued that too many births in Kentucky are paid for by Medicaid, the joint federal-state insurance program for low-income Americans.

According to Kentucky’s Cabinet for Health and Family Services, Medicaid pays for about half of the state’s 57,000 annual births. Paul is quoted by the Associated Press as saying that “Half of the people in Kentucky are not poor. We’ve made it too easy.”

In reality, paying for a pregnancy can be anything but easy. According to the March of Dimes, maternity care costs more than $8,800 (pdf), on average, and these costs can quickly escalate into the tens of thousands of dollars if complications arise (for instance, in the case of a premature birth).

That’s why having insurance coverage is so critical. Employer-based group plans usually have good maternity care coverage, but most low-income women don’t get insurance through the workplace. And the National Women’s Law Center has documented that in the individual insurance market, few plans include maternity care coverage (pdf) at all.

The recently enacted health care reform law would require all private insurance plans to cover maternity care starting in 2014. Meanwhile, however, insurance trends are moving in the wrong direction.

According to a Guttmacher Institute analysis of new Census Bureau data, 2.3 million reproductive-age women lost private insurance coverage between 2008 and 2009 alone, bringing the total covered to fewer than six in 10.

That’s where Medicaid comes in. While income eligibility ceilings under the program in general are usually well below the official federal poverty line, federal Medicaid law requires all states to cover pregnancy-related care for women with incomes up to 133 percent of poverty. Kentucky and most other states have — wisely — decided to raise that level even further. Still, Kentucky’s eligibility, at 185 percent of poverty (which is typical among the states), amounts to only about $34,000 a year for a family of three.

Medicaid’s role in providing quality care for low-income pregnant women and their infants is not only a moral imperative. It’s also sound public health policy, considering the many negative health consequences that await mothers and children if they do not obtain appropriate care.

Financial hurdles — particularly for the uninsured and underinsured — can lead to delayed or substandard care, and are an important reason why the United States lags behind most other developed countries in rates of maternal mortality and preterm births.

Another reason is that so many pregnancies in the United States, particularly among low-income women, are unintended — making Medicaid coverage of family planning services equally critical. Publicly funded contraceptive counseling and services empower low-income women to prevent pregnancies they don’t want to have and become pregnant only when they want to be, thereby maximizing their chances of having a healthy pregnancy and giving birth to a healthy infant.

Realizing these significant health benefits, 21 states have also increased their Medicaid income eligibility ceilings for family planning services (pdf), often pegging them to the same income level they have for pregnancy-related care. (Kentucky, unfortunately, is not one of them, but nearby states like Virginia, Arkansas and Missouri are.)

The impact is significant: Publicly funded family planning services — the bulk of which are provided by Medicaid — avert 1.94 million unintended pregnancies each year. These pregnancies would result in 860,000 unintended births, 810,000 abortions and 270,000 miscarriages.

Given these benefits, conservatives of all stripes, including Paul, should strongly support publicly subsidized contraceptive services. Fiscal conservatives should applaud the fact that, by helping low-income women prevent births they themselves do not want to have, these services save almost $4 in public expenditures for every $1 invested.

Social conservatives should be reassured that without them, the U.S. abortion rate would be two-thirds higher than it is. And pro-business conservatives should appreciate the value of enabling women to postpone childbearing while they complete their education, undergo job training or establish themselves in their career.

In short, Medicaid’s role as the safety-net insurer of both pregnancy-related care and family planning services is essential to the health of millions of American women and infants. It truly is smart, fiscally responsible government at its best—and it deserves support from across the political spectrum.

Cory L. Richards is the executive vice president and vice president for public policy at the Guttmacher Institute

Related: For more information, check out these articles from Guttmacher:

• The potential of health care reform to improve pregnancy-related services and outcomes
• The impact of the recession on reproductive-age women
• State-level data on the insurance status of reproductive-age women (Insurance Status, under Services and Financing)
• Contraception as an integral component of preventive care for women
• The impact of publicly funded family planning services
• States that have expanded Medicaid eligibility for family planning services (pdf)

This week is National Midwifery Week, in which organizations and individuals promote midwifery and try to raise awareness about midwifery services.

The American College of Nurse-Midwives provides an online toolkit for promoting the observance, including a list of Things You Can Do to Celebrate National Midwifery Week. My favorite suggestion, given my librarian bias: “Request your local librarian to create a special display of available books about the women’s health, childbirth, midwifery, and literature inspired by or mentioning midwives.” Nebraska Friends of Midwives has some great tips for working with libraries on such displays, although they require a bit of advance preparation – you might want to bookmark them for next year!

The organization also issued a press release, and has a series of guest posts at its blog, Midwife Connection. Where’s My Midwife? has additional activity suggestions, and RH Reality Check is hosting a series of posts on midwifery this week, the first from the perspective of an American midwife working in Haiti.

California Governor Arnold Schwarzenegger has vetoed AB 1900, a bill requiring the Corrections Standards Authority to develop standards on the shackling of pregnant women, and to prohibit pregnant inmates from being shackled by the wrists or ankles during transport, labor and delivery, and recovery, unless deemed necessary for safety.

The veto is somewhat surprising, because the bill was approved unanimously every time it came up for a vote in the state Senate and Assembly.

The Governor argued in his veto that the bill “would require the Corrections Standards Authority (CSA) to develop guidelines concerning the shackling of pregnant inmates and wards during transport. However, CSA’s mission is to regulate and develop standards for correctional facilities, not establish policies on transportation issues to and from other locations.”

I’m no expert on the correctional system in California, so I don’t know whose job it would be to set standards on inmate transport if it is not the CSA’s. Do any of our California readers have any insight on this?

In a commentary for the San Francisco Chronicle, Karen Shain of Legal Services for Prisoners with Children called the veto “particularly mean spirited” and described the bill as “an inexpensive solution to a human rights problem.”

Jodi Jacobson at RH Reality Check has additional commentary. Please also see our previous posts on the shackling of pregnant inmates for further background and discussion.

From Amnesty International:

Beginning September 20 at 9 a.m. EST, the start of the Millennium Development Goals Summit, the Maternal Death Clock began to tick – keeping track of the total number of maternal deaths in the world.

September 20-22 world leaders are gathering in New York to chart a course forward on the Millennium Development Goals (MDGs) – the framework that will guide the fight against global poverty through 2015.

The one goal aimed at decreasing maternal deaths has fallen far short of where it needs to be to meet the MDG target of cutting maternal deaths by 75% by the target date.

Hundreds of thousands of women and girls continue to die in pregnancy and childbirth each year. Most of them live in developing countries and low-income communities. In fact, one woman dies in childbirth every 90 seconds.

Join Amnesty International in making sure that human rights are at the heart of the MDGs!

If you go to the site, there’s a petition, more information, and code for embedding the death clock widget.

The World Health Organization, with UNICEF, UNFPA and The World Bank, has released a new report on trends in global maternal mortality from 1990-2008. I haven’t read the full report yet, but according to the press release, “the number of women dying due to complications during pregnancy and childbirth has decreased by 34% from an estimated 546,000 in 1990 to 358,000 in 2008.”

Although this is great progress, the release points out that more work needs to be done:

The progress is notable, but the annual rate of decline is less than half of what is needed to achieve the Millennium Development Goal (MDG) target of reducing the maternal mortality ratio by 75% between 1990 and 2015. This will require an annual decline of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%.

A recent New York Times piece, Majority of Caesareans Are Done Before Labor, discusses a study on cesearean section by the Consortium on Safe Labor. The actual study report covered by the Times is currently an “in press” article from the American Journal of Obstetrics and Gynecology, entitled “Contemporary cesarean delivery practice in the United States” with lead author Jun Zhang.

The researchers reviewed the medical records from more than 200,000 births at 19 hospitals around the country. The authors report an overall cesarean rate of 30.5%, varying from 20% to 44% among different hospitals, with a rate of 31.2% for first births (and 30.0% for women with previous births).

According to the Times, “Dr. Zhang said one thing that surprised him about the study was that a third of first-time mothers were having Caesareans. Although it was known that the overall Caesarean rate was 32 percent, some of that was thought to be due to repeat Caesareans.”

That finding is pretty similar to the figure provided in recent CDC report, which indicated that the cesarean rate was 23.9% for first births in 1990, decreased slightly in the mid-to-late 1990s (to around 21% for a few years), and then increased up to 27.1% in 2003. We know that the rate of cesareans overall has continued to increase since 2003 (where the CDC report stopped), so it’s not altogether surprising that Zhang et al (whose study covered 2002-2008) found an even higher rate (31.2%) among the first-time moms in the study.

The paper includes quite a bit more data and analysis on various factors. There is too much to detail all of it here, but here are some snippets highlighted by the authors:

• The induction rate was 36.2% overall, and 43.8% among women attempting vaginal delivery.
• The cesarean rate was twice as high in induced labor than in spontaneous labor overall (21.1% vs 11.8%).
• In women with a previous uterine scar, only 28.8% had a trial of labor, which the authors called “disappointingly low.” Among them, the rate of successful VBAC was 57.1%.
• Almost all (92.8%) of the nonvertex presentations were delivered by cesarean.
• Just over half of the cesareans were “prelabor,” with the most frequent reason being a previous cesarean.

The authors conclude with this statement on the increasing cesarean rate in the United States:

To make a significant impact on the high cesarean delivery rate in the United States, the focus should be preventing unnecessary primary cesarean deliveries from several aspects. First, we need to decrease the rate of cesarean delivery associated with a high rate of induction of labor. Cesarean section for dystocia should be avoided before active phase of labor is established particularly in nulliparous women, induced labor, and VBAC attempts. Second, there should be a clinically accepted indication for performing cesarean delivery. Finally, increasing access to and patient education on trial of labor in women with a previous uterine scar and improving the success rate are urgently needed.

Related: I haven’t checked it out myself yet, but recently learned about A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a VBAC advocacy project inspired by the recent NIH consensus development conference on VBAC.