In November, 2011, Centers for Disease Control and Prevention released their preliminary National Vital Statistics data for 2010. Included in this data is a minor decrease in cesarean section rates-from 32.9 percent in 2009 to 32.8 percent in 2010-representing the first drop in this mode of childbirth since 1996. While evidence in the current medical literature exists to sufficiently tie increased cesarean section rates to maternal morbidity and mortality, we have continued to witness a climb in this mode of childbirth until this past year (Shiliang, et al. 2007). In an effort to decrease poor maternal outcomes with the excessive (not entire) use of this mode of delivery, a multi-level, economic approach might be implemented.

It is well known that cesarean surgery carries a much higher price tag than vaginal delivery. According to Childbirth Connection, an uncomplicated cesarean birth costs nearly $16,000 and an uncomplicated (hospital) vaginal birth costs around $9,000 (a 64% reduction). According to the most recent, 2009 data available from the Agency for Healthcare Research and Quality, 54.82% of the 4 million U.S. births are paid for by the government-funded Medicaid program. This inadvertently represents a great opportunity to financially incent hospitals, corporate insurers and maternity care providers to decrease surgical birth rates.
Dr. Armour and colleagues described the efficacy of clinician incentive programming in their article, The Effect of Explicit Financial Incentives on Physician Behavior (2001). And while clinicians like Dr. Ronald Cyr argue there is no 'perfect' cesarean section rate, many will agree that nearly 33% is far too high (2006). The development of a top-down program to encourage maternity care provider practice alteration might look as follows:

U.S. government commits to offering x% annual tax deductions to corporate insurance companies that participate in a 'Decreasing Maternal Morbidity and Mortality' program. Those insurers, in turn commit to offering x% decrease on annual premiums to their client maternity care facilities, for every x% each facility decreases its annual c-section rate. The participating hospitals, in turn, offer x% annual bonuses to each (employee) maternity care provider who decreases their annual c-section rate by x%. The real and perceived benefits are numerous under this program: the government, which covers the cost of pregnancy-related healthcare in over 50% of U.S. women through Medicaid, realizes decreased expenditures from decreased cesarean delivery rates. Corporate insurers have the potential to see decreased expenses from malpractice litigation and other financial externalities that accompany intra- or post-operative complications. Additionally, they would benefit from the tax deduction portion of the program. Hospitals would financially benefit from malpractice insurance premium reductions as well as the sometimes-absorbed costs of post-surgical complications. Also, they would likely experience an increase in community perception of their commitment to improving maternity care practices through highly publicized decreases in surgical births and post-operative complication rates. Maternity care providers would benefit financially from bonuses, as well as public perceived commitment to evidence-based maternity care.

This economic incentive program would be further enhanced by increasing public demand for participating maternity care facilities. Through a public education portion of the Decreasing Maternal Morbidity and Mortality program, publication of the names of participating facilities would aim to:

• increase the general public's knowledge of the importance of maintaining sufficiently low (but not absent) cesarean section rates and
• increase the general public's awareness of hospitals and providers who are committed to decreasing this rate.

This increased consumer demand, while not strictly on a financial supply-demand curve, would surely prompt an increase in the supply of facilities and providers boasting this dedication to evidence-based labor and delivery practices-least they suffer a decrease in patient census as women take their maternity care needs elsewhere (Ensor, 2004).

In tomorrow's final post in this series, I will suggest federal, state and institutional level policies which might be employed to tackle the rising U.S. maternal mortality and morbidity rates.

Published: January 05, 2012

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