Snapshot Legislation

Today the public has a much bigger picture of the high rates of maternal mortality, preterm birth, still birth, and neonatal death in the U.S. thanks to journalism from investigative reporting such as that of ProPublica and NBC News. The problem is that the people who could be or should be interested in this process, such as the American College of Obstetricians and Gynecologists (ACOG), are doing little or nothing to bring about the kinds of changes in the healthcare system that could save our moms, kids, and dads.

The Centers for Medicare and Medicaid Services (CMS) will be spending a lot of money studying their offerings for the next 8 or 10 years. This year alone, the CMS budget to support maternal mortality initiatives in the U.S. is $376 million. According to the National Institutes of Health (NIH), its annual “healthcare research” budget is more than $45 billion. The NIH is the single largest public funder of biomedical and behavioral research in the world. It is obvious that $376 million designated for research of maternal mortality and stillbirth is a small number compared to the $45 billion at NIH’s disposal.

In the U.S., the poor results with legislative problem-solving in healthcare is that complex issues require extensive knowledge of what is really going on in the trenches to create effective solutions. Most legislators lack this knowledge and see only a sliver of the big picture, or worse yet, may not realize they don’t have the big picture. Most legislation is reduced to single issue problems with no understanding of how the proposed solutions may not fit the bigger picture. As a result, this snapshot legislation causes more problems rather than solving the problems.

Some of you may remember the uproar over the side rails on hospital beds. Legislators were presented with a snapshot of a patient’s head stuck in the side rail of a hospital bed. As a result of this picture, legislation was passed to eliminate side rails on hospital beds. Unfortunately, those passing this legislation obviously didn’t stop to think about the whole picture. Side rails had been saving lives for many decades. Patients could fall out of beds, injuring their backs, their hips, their legs, or their shoulders. So overall, the side rails did much more good than they did harm. So a solution was never sought to design a safe bed rail. Rather, legislators simply banned bed rails with little thought as to how this would affect patient care.

A simple and safe solution costing one percent as much as eliminating hospital bed rails would have been to simply change the design of the bed side rail to remove the bars and eliminate the spaces which might entangle patients. Instead, our legislators made a drastic decision to eliminate bed rails. This simple decision by legislators created a boon to the hospital bed manufactureres. Many hospital beds had to be replaced so the bed could be lowered closer to the floor than the standard hospital bed.

One hospital bed can cost around $8000, so this was a tremendous expense for the hospitals and a huge profit for the hospital bed industry. Instead of the bed side rails, the beds now had foam cushions that were supposed to be placed in the bed to prevent the patients from rolling out onto the floor. There were also foam cushions on the floor so that when the patients rolled out of bed anyway, they would have some protection from breaking bones. Whether any of that really worked or not we don’t know because there was never a study by the Centers for Disease Control and Prevention (CDC) to document whether the changes made any real difference in protecting patients from harm.

The government has not bothered to calculate the horrendous cost of replacing all of the beds and finding things that would in some way provide the protection afforded by the bed rails. Then there’s the issue of foam being a good growing medium for bacteria whereas the bed rail could be sanitized. The other cost that we haven’t begun to calculate is the cost of the broken bones and deaths that occurred because patients fell out of bed.

In my experience, it is typical for federal and state legislators to fail to see the big picture when they create legislative solutions to practical problems such as how to protect patients from possible harm from their bed rails.

Now, with the increasing maternal mortality, stillbirth, and preterm birth rates, the public is pressuring the federal government for solutions. Patients are doing this out of desperation because the organizations that should be actively pursuing these goals such as ACOG are not leading the movement for substantive change in the U.S. maternal mortality and stillbirth rates.

With proposals for federal and state government funding, the solution is to spend lots of money doing research by collecting data.  On June 11, 2024, the Merkley-Cassidy (M.D.) bipartisan bill to address America’s stillbirth crisis had nearly become law. The Maternal and Child Health Stillbirth Prevention Act of 2023, amends Title V, the Maternal and Child Health Services Block Grant of the Social Security Act, to clarify that stillbirth prevention activities and research are allowable use of funds. Big deal!

According to Merkley’s web site about his bill, the World Health Organization has compared progress in improving stillbirth rates.  The U.S. ranked 183 out of 195 countries. That is, there are 182 countries with lower stillbirth rates than the U.S. Somehow, as if by magic, this bill will, “help bring down the shockingly high rate of stillbirths and maternal mortality in the United States by opening up more federal resources, (money) for “stillbirth prevention activities” and “research.”

Of course, the devil is in the details. What “stillbirth prevention activities” would be include aren’t specified. We do know that “research” is just another way to spend money collecting data, but at least spending money has the appearance of getting something done and of caring.

As I noted in my previous Substack article on decreasing stillbirths, the fastest, most effective, and cheapest way of decreasing stillbirths would be to train mothers to use the kick test. Discussing the kick test with the patient has many advantages. Certainly, it serves to establish a conduit or effective means of communication between doctor and patient. It also requires a discussion of fetal welfare and brings the mother into the process to help protect her baby.

Many patients indicate that their providers have not discussed the possibility of stillbirth. Many providers defend this position by using the excuse that they don’t want to scare consumers. Actually, I think the main reason this discussion seldom comes up is because physicians don’t want to take the time or are employed by a healthcare system which allows them to spend only so much time with patients. I know from experience that discussions of fetal health, the fetal kick test, and stillbirth is a time consuming conversation.

Using the fetal kick test with my patients, my stillbirth rate was approximately one in 3000 births. These numbers would be considered by researchers as “anecdotal,” that is, untested. But the results are real. My primary recommendation in how to bring down the U.S. stillbirth rate is to require obstetricians to take time to work with their patients and teach their patients how to do the kick test. This doesn’t need to be a law. Any obstetrical practice could incorporate teaching their patients how to do the kick test into their practice routine and I believe see their stillbirth numbers go down.

And if obstetricians will not voluntarily participate in an effort to work with their patients with the kick test, the beauty is that any mother can learn how to do the kick test by herself at home. No snapshot legislation needed.