To study severe morbidity, the CDC analyzed more than 50 million maternity records from the Nationwide Inpatient Sample from 1998 to 2009 (Callaghan, 2012). They used ICD9-CM codes and reported that 129 per 10,000 of these gravidas had at least one indicator for severe morbidity (Table 1--).hus, for every maternal death, approximately 200 women experience severe morbidity. he CDC (20 17b) estimates that 65,000 women per year have such maternal morbidity. These numbers are greatest in smaller hospitals with < 1000 deliveries annually (Hehir, 2017). Finally, as with mortality rates, there are serious racial and ethnic disparities for severe maternal morbidity, and black women are disproportionately afected (Creanga, 2014).
Various topics have been in the forefront for obstetrical providers in the 4 years since the last edition of this textbook. In the following, we discuss several of these topics.
• U.S. Health Care in Crisis
In a 2016 issue of the Jounal of the American Medical Association fAA), then-President Barack Obama presented a summary of the Afordable Care Act (ACA), so-called Obamacare. He described the successes, the challenges ahead, and the policy implications of the policy (Bauchner, 2016). He summarized three lessons from his experiences with the ACA. First, change is especially diicult in the face of hyperpartisanship. Second, special interests pose a continued obstacle to change. Third, he stressed the importance of pragmatism. Here, he was referring to the pragmatism necessary when the ACA did not work efectively on day 1 of implementation.
TABLE 1-3. Severe Maternal Morbidity Indicators
Injuries of thorax, abdomen, and pelvis Intracranial injuries
Conversion of cardiac rhythm Hysterectomy
Summarized from the Centers for Disease Control and Prevention,l2017b.
At this same time, draconian cuts to Medicaid were being proposed, and President Obama ended his JM1A report with a quotation from John Kasich, the Republican governor of Ohio. "For those that live in the shadows of life, those who are the least among us, I will not accept the fact that the most vulnerable in our state should be ignored. We can help them." hese potential efects to Medicaid ripple into the specialty of obstetrics. In 2010, it was estimated that Medicaid insured 48 percent of the births in the United States (lvlarkus, 2013). Importantly, Medicaid covered a disproportionate number of complicated births. Speciically, Medicaid insured more than half of all hospital stays for preterm and low-birthweight infants and approximately 45 percent of infant hospital stays due to birth defects.
he young, healthy Americans who were expected to financially bolster the ACA ultimately enrolled in insuicient numbers to ensure long-term ACA sustainability. hus, long-term options included repair or repeal of the ACA. hroughout Donald Trump's campaign for the presidency of the United States, he made repeal of the ACA a focus of his candidacy. As of this writing, both the United States House of Representatives and the Senate have grappled with "repeal and replace" for 6 months. According to the Congressional Budget Oice, this action would result in 23 million Americans losing health care insurance and cuts in Medicaid dollars (Fiedler, 2017). he latter was to be accomplished by transferring funding of Medicaid from the Federal government to the states.
Overview of Obstetrics 7 hese potential outcomes have prompted considerable debate among voters, and "repeal and replace" has become politically charged. Currently, the Senate has been unable to recruit suficient Republican votes for Senate passage of such a bill. We suggest that the health care crisis should be reframed and redirected instead to a critical analysis of health care costs and resource utilization.