NICUs: If We Build It, They Will Come?
April 13th, 2009 by Amy Romano
A doula friend of mine was telling me recently about the seemingly arbitrary variation she sees across the different hospitals where she attends births. “In one hospital they always turn the epidural off when the woman is ready to push, and in another hospital just a few miles away we had to fight to get a client’s epidural turned off while she pushed.” In both cases, the woman was given only one choice, and that choice was dictated by whatever the standard practice was, regardless of the evidence, her particular circumstances, or her preferences. “Women assume that things are the same no matter where they give birth,” the doula told me. “They can’t make informed choices if they don’t know this stuff.” (This is why this doula and are I are working together to promote The Birth Survey in our state.)
In research and policy-making, these differences are called “practice variation,” and in obstetrics there is plenty of it. Some variation in practice across settings or providers makes sense – women or their babies may have different needs depending on their health status, risk factors, or preferences. But what’s troubling is that a lot of practice variation arises from factors that have nothing to do with women or their babies, and everything to do with the approach to care. Do women know that their risk of episiotomy may be as much as 7 times higher if they go to a private OB practice rather than a public clinic? Do low-risk first-time mothers know that the hospitals where women are most likely to be induced or admitted early in labor have c-section rates 3 times higher than other hospitals that restrict those practices? (And how do they know which hospitals those are, anyway?) Do women who have had a cesarean know which hospitals restrict or deny access to VBAC?
A new study published in the current issue of The European Journal of Obstetrics, Gynecology, and Reproductive Biology illuminates another troubling consequence of practice variation. Researchers studied the outcomes of over 3500 full-term babies born to low-risk, first-time mothers in 138 French maternity units. Thirty-four were “level 1” units, where there are no special facilities for caring for sick neonates, and babies needing such care are transferred to other facilities. Sixty-six were “level 2” units, where special care nurseries are available to care for some sick newborns as well as preterm babies born at or beyond 32 weeks. The remaining 38 units had intensive care units capable of caring for very sick and preterm babies, and had 24/7 availability of neonatologists. The researchers were careful to compare apples with apples. In addition to restricting their analysis to healthy mothers with full-term babies, they used statistical adjustments to control for other factors that could affect outcomes like the mother’s age, the mode of birth, and the baby’s gestational age and birthweight.
The results they reported show that the level of hospital is itself a risk factor for a baby being admitted for special or intensive care. Babies born in the level 1 hospitals were most likely to stay with their mothers after birth. Babies born in level 2 hospitals were twice as likely to be admitted for special or intensive care, a difference that was statistically significant. Babies born in level 3 hospitals were also more likely to be admitted to special or intensive care, but the difference was not statistically significant.
I am not aware of any US studies looking at the association between the presence of a NICU and the likelihood that a full-term baby born to a healthy mother will be admitted there. However, in our market-based health care system, NICUs are major money makers for hospitals. Admission to the NICU drives costs way up for consumers and payors, and is a dismal way for a baby to start life. We know that optimal maternal and newborn wellbeing occurs when mothers and babies stay together in the hours and days after birth, so the goal of a functioning health care system should be to keep as many babies with their mothers as possible, without compromising safety or wellbeing.
NICUs should be there for the babies who need them. Babies should not have to be there for the NICUs that need them.
Citation: Le Ray, C., Zeitlin, J., Jarreau, P. H., Breart, G., Goffinet, F., & for the PREMODA study group. (2009). The influence of level of care on admission to neonatal care for babies of low-risk nullipara. European Journal of Obstetrics, Gynecology, and Reproductive Biology, doi: 10.1016
