Will vaginal birth after Cesarean section (VBAC) make a comeback?

Will vaginal birth after Cesarean section

My daughter, who moves around three years old in June, is becoming something of a medical rarity. This isn't because she causes a congenital disorder or extraordinary ability for her age; it's because she came into the universe as a vaginal birth after Cesarean section (VBAC). Although 75 percent of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly higher risks of uterine rupture with VBAC, concerns about lawsuits, and restrictive guidelines discourage most women from trying. After reaching a high in 1996 of 28.3 percent of U.S. women who previously delivered by Cesarean, the VBAC rate today is considerably less than 1 in 10.

The AAFP's 2005 guideline on trial of labor after Cesarean (TOLAC) noted that there was no good evidence that having surgical and anesthesia personnel "immediately available" (i.e., on site) during a trial of labor, as required in a 1999 ACOG guideline, improves maternal or infant outcomes. At an NIH conference last year, an expert panel also concluded that the scientific evidence did not support ACOG's position. However, the panel found that this restrictive requirement had led many hospitals without 24-hour availability of these services to discontinue VBAC entirely.

The January 15th issue of AFP summarizes the updated ACOG recommendations on VBAC, which state that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by immediate access to emergency resources, the guideline adds: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have Cesarean delivery or to deny care to women in labor who decline to have a repeat Cesarean delivery."

In a thoughtful and informative editorial in the January 15th issue, "Increasing Patient Access to VBAC: New NIH and ACOG Recommendations," Lawrence Leeman, MD, MPH and Valerie King, MD, MPH write:

We encourage maternity care providers and hospitals that do not currently offer TOLAC to use the NIH statement and revised ACOG guidelines as an opportunity to reevaluate their policies on TOLAC. The Northern New England Perinatal Quality Improvement Network's VBAC project is an example of a collaborative effort between community hospitals and maternity care providers to develop risk-stratification guidelines and to facilitate planning for emergent cesarean delivery. Counseling patients about delivery options involves consideration of maternal and perinatal risks and benefits, future childbearing plans, and the likelihood of successful VBAC. Most women who have had a previous cesarean delivery are candidates for TOLAC and should be offered that option.

Affective memory

The term ‘affective memory’ was intended to include emotional and sensory phenomena, and to differentiate them from intellectual, volitional or rational ones.

It is basic in functional perspective. Pain and pleasure are information that control behavior.

Boleslavsky divided affective memory into two categories: analytic memory, and the memory of feeling. Analytic memory is trained and developed by exercise involving imaginary objects.

The second category that Boleslavsky described was the memory of feeling, which can be called emotional memory.

The term affective memory was taken by Stanislavsky from a work by the French psychologist Theodule Ribot, The Psychology of the Emotions.

Strasberg in turn defined ‘affective memory’ as a broad category containing both ‘sense’ memory and ‘emotional’ memory. He states, ‘pertains specifically to the more intense reactions of an emotional response’.
Affective memory

What can Rwanda teach the U.S. about primary care?

The relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of a 2013 Atlantic headline: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to 38% of eligible U.S. girls in 2013.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.

Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this:

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that don't require imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.

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This post first appeared on Common Sense Family Doctor on December 2, 2013.

Medicine and the not - so - free market

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National Post View

In the health care reform debate, some people argue that the solution to skyrocketing cost of health services is to encourage more "free market" competition to lower prices, rather than expanding public funding and controls. There is some value to this argument; generic drugs, which cost as little as $4 for a 30-day supply at national retailers such as Wal-Mart, Target, CVS, and Giant, have helped to take a bite out of many people's prescription costs.

Unfortunately, most of American medicine does not function like a free market or obey the laws of supply and demand. In an true free market, the supply of MRI machines would correspond to the number of scans that needed to be performed. In fact, MRI machines are huge money-makers for hospitals and radiology practices, which create their own artificial demand. Instead, the maxim uttered by Kevin Costner in "Field of Dreams" (If You Build It, They Will Come) applies. The more MRI scanners there are in a given city, the more MRI scans will be done, regardless of the actual need for this test. Every few days, I get a phone call from a private radiology unit in the DC area to "let you know that we have open appointments for today, just in case you need to refer a patient to us." While I'd like to think that I wouldn't order an MRI for something like back or neck pain unless it was really needed, same-day availability is awfully tempting to physicians and patients. (This also explains why there are so many more MRI machines in the U.S. than there are in Canada. It isn't that they have too few, it's that we have many more than we actually need.)

This practice isn't limited to Radiology, either - for examples of how the availability of procedures drives up costs related to heart procedures, see Atul Gawande's recent piece in the New Yorker. Build a cardiac catheterization laboratory, and more catheterizations will be performed. Build more hospital beds, and more patients will be admitted instead of sent home for treatment.For the past quarter century, a team of researchers at Dartmouth has been using data from Medicare to produce an atlas that documents wide variations in health resource utilization across the U.S. Not only have they found that where you live has everything to do with how much health care you receive, but there is no relationship between cost and quality of that care. So much for the free market!

Why “government-run health care” can be good for you

Why “government-run health care” can be good for you

Many politicians and television commentators are making "government-run health care" sound like a string of dirty words. I have a different view. To me, government-run health care makes me think about a patient I cared for during my family medicine residency - I'll call him Ed - whom I met while volunteering at a free clinic in Lancaster, PA. Ed was a well-educated man: he had a Masters in Divinity and formerly directed a nonprofit. But at that point he was just beginning to climb out from a disastrous time in his life, having fallen victim to alcohol and heroin addiction and losing his job, home, and family. A few months earlier he learned that he had diabetes, but having no health insurance or primary care doctor, Ed let his sugar level spiral out of control until he was hospitalized in a coma from diabetic ketoacidosis, an often fatal condition when the body's metabolism, unable to turn sugar into fuel, produces waste products that dangerously acidify the blood. Fortunately, doctors were able to reverse the process in time, and Ed pulled through.

Ed arrived at the clinic for his post-hospital follow-up visit the night I happened to be volunteering. I almost couldn't believe my eyes as I reviewed the laboratory results and hospital records he brought with him. He was lucky to be alive. Unfortunately, he had been prescribed several medications that, having virtually no income and living in a homeless shelter, he couldn't possibly afford. The clinic stocked some donated medications, but not nearly enough to supply Ed's needs for more than a few days - after which his diabetes would inevitably worsen until he would be back in the hospital again, or worse. Through a social worker at our hospital, I helped Ed apply for Pennsylvania Medicaid (health insurance administered by state governments with federal government subsidies), and was able to see him in my regular office.

I cared for Ed for nearly 2 years. During that time, we not only controlled his diabetes, but he was able to get back on his feet emotionally, spiritually, and financially, eventually moving into his own apartment and holding down a paying job as a counselor. That's what "government-run health care" can do. And if you're thinking that you'll never be stuck in a situation similar to Ed's, I'd ask you to consider what you would do if you suddenly lost your job, if you were disabled in an accident, or some other financial catastrophe happened to your immediate family or friends. The "safety net" isn't enough. Several national organizations representing primary care physicians recently came to the same conclusion; you can see their powerful message on the website Heal Health Care Now.org

Biased research; aggressive sales, and harmful drugs

Biased research; aggressive sales, and harmful drugs

Commendation from the U.S. Food and Drug Administration to market a novel drug is a critical waypoint along the path to profits for pharmaceutical producers. Alas, recent case studies have illustrated that FDA approval does not necessarily provide assurances of effectiveness and safety. In this month's Georgetown University Health Policy seminar, we hashed out two examples, anemia drugs and the diabetes drug rosiglitazone (Avandia), which were prominently featured in recent articles by Peter Whoriskey in The Washington Post.

The original impetus for the evolution of the anemia drugs Epogen, Procrit, and Aranesp, which mimic the  actions of the hormone erythropoietin, was to spare dialysis patients with severe anemia the inconvenience and hazards associated with occasional blood transfusions. Still, noted Whoriskey, pharmaceutical companies moved aggressively to market these drugs to a far larger patient population who were much less likely to benefit from them:

The difficulty would arise as the drug makers won FDA approval for vastly expanded uses, forcing it in larger dosages, for milder anemia and for patients with a broader array of maladies. Real rapidly, the market included nearly all dialysis patients, not only the roughly 16 percent who needed blood transfusions. The size of average doses would more than triple. And o'er the following five years, the FDA would approve it to treat anemia in patients with malignant neoplastic disease and AIDS, as easily as those getting hip and knee surgical procedure.

Doctors were motivated to give more doses of these drugs due to generous financial incentives (estimated at between $100,000 and $300,000 per year for a typical oncologist) and the seductive thinking that if some drug was good, more was better. Even the publication of a 1998 study in the New England Journal of Medicine showing no survival advantage to boosting hematocrit levels to normal ranges in cardiac patients did little to discourage overprescribing. Not until 14 years later did an independent researcher obtain access to the complete study report from the FDA and conclude that the NEJM authors had used statistical slight-of-hand to obscure an increased danger of heart attacks and dying in the normal-hematocrit group. In the meantime, lobbyists working for the drug manufacturers successfully blocked efforts by Medicare administrators to finish compensating for the higher (harmful) doses.

Likewise, the evidence that rosiglitazone (Avandia) increased the danger of heart attacks was slow to come to light, due in part to the drugmaker's research emphasis on the surrogate outcome of glycemic control. Although a 2007 meta-analysis first sounded the alarm about rosiglitazone's cardiovascular risks, the manufacturer successfully stalled regulatory action in the U.S. for three more years, during which thousands of new patients were prescribed the drug.

Could the FDA and other U.S. government authorities act more to protect patients from the effects of biased research and aggressive sales tactics for newly marketed drugs? What concrete steps could health policymakers take to encourage research to identify unexpected harms earlier in the drug approval procedure?