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The Making of Beginnings Guides
The 7th Attribute - Navigation Assistance
CORRECTION: The discussion paper posted here yesterday
New IOM Discussion Paper on Health Literacy


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Government shutdown is all FUD

FUD: Fear Uncertainty & Doubt. That is the foundation of the extreme House
Republican’ position on the Patient Protection and Affordable Care Act of 2010.
That’s why they call it Obamacare- in order not to say “protection” or “affordable”;
and  to hide the fact that the law was enacted 3 years ago, before the President
was soundly re-elected running against an opponent who vowed to repeal it.
FUD, initially an IBM strategy to eliminate market competitors by spreading fear
uncertainty and disinformation about their products, seems to be working for the
House Republicans. At least to some degree, for now. Polls and analyses of social
media suggest that some people favor the Affordable Care Act while opposing Obamacare.
Home visitors: “Obama snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper tantrum until I saw
the Fox “news report” about the Affordable Care Act’s expansion of home visitation.
That’s  a preventive strategy in which public health nurses, social workers or trained
paraprofessionals connect families to healthcare and community resources and offer
health education and social support.  It’s origins date back to the 1800s. Programs
are run by county health departments, school districts, foundations, and private-public
partnerships. Home visiting programs are open to poor parents who request assistance.
It’s worth noting that in many countries, home visiting has long been standard for all
parents, because they acknowledge that parenting is a challenge and everyone can
use assistance. And because research shows it improves child developmental outcomes
and has immediate and long-term benefits that extend to entire families and to the
healthcare, education and justice systems. My researchshows that parents in home
visitation significantly improve their health literacy, capacity to manage personal and
child health and healthcare.
Pure FUD
A Fox announcer and a “business expert” called home visitors “Obama snoopers". 
They said  in this “brand new federal program”, “government home inspectors”
make random, unannounced  “forced home visits” to snoop on parents.  This is not
news. This is pure FUD - disinformation (lies) that specifically intends to instill fear,
uncertainty and doubt about the Affordable Care Act, to prevent people from learning
they can afford good healthcare coverage.
I have worked for decades with home visitors and know them to be among the most
caring, dedicated, respectful people on the planet, unlike the FUDders on Fox and in
the House.
FUD won’t work for long. Yesterday, the heart of the Affordable Care Act started
(keep saying the real name), opening access to healthcare for millions of poor and
uninsured citizens. Almost 3 million people visited www.heathcare.gov State exchanges
were similarly overwhelmed.  People are about to find out that the Affordable Care Act
makes good healthcare coverage affordable -for them. That will help them see through
the FUD.  Insurance companies are helping too. They are enrolling people they previously
rejected because, with the ACA, it’s good for business. Healthcare executives are calling
for more doctors, nurses and allied health professionals - doesn’t really sound like a
“job-killer” does it?
On the other hand, the House Republicans just put hundreds of thousands of people out of
work in hopes they can FUD us citizens of the richest country in the world into continuing
denying healthcare to poor people and sick people in order to preserve the freedom of
the rich to get richer.

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
life across cultures. They are skills that empower people to  be what
they want to be, to make choices and transform those choices into desired
actions and outcomes. 
These life skills develop most easily in early childhood given a stable
supportive family environment. Disparity in brain development in children
growing in disadvantaged vs enriched environments becomes apparent in
the first year.  Quality of family life matters more than the number of
parents, their income or education. But poverty and accumulated disadvantage
prevent parents from doing their best to sustain the stimulating home
environments that support optimal development, especially when they
themselves lack skills, resources and role models. Early intervention ---
early childhood education, parenting training, family support and home
visitation programs--- can produce positive and lasting effects on children
in disadvantaged families.  
Nobel Laureate and economics professor James Heckman, makes the business
case for shifting public policy to support programs that offer parents information,
choices and assistance.  Promoting health literacy means providing direct
supplemental assistance that specifically and intentionally enables parents to
develop and hone the range of life skills used to participate in healthcare and
manage personal and family health at home.
Must read: Heckman,  James J. (2013) Giving Kids a Fair Chance (A Strategy
That Works) MIT Press, Cambridge, Mass.  ISBN 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary
by 10 experts from multiple disciplines.

Promoting Health Literacy with Beginnings Pregnancy Guide New Online: Resources for Mothers

My favorite feature of the upcoming 9th edition of the Pregnancy Guide recognizes
it is a digital world. You told us that you and your families need print materials since
few in your caseloads have computer access or devices to use digital information.
Other surveys confirm you’re right.
Poverty and the Digital Divide
In December 2010, 40% of  US households, did not have a broadband connection in
the home.  Lack of access is a marker of poverty. Mississippi is the poorest state
and has the highest proportion of households without access, 65%. Similar rates of
poverty and no-access are found in AR, TN, WV and OK.  Compare to wealthy
states led by HI with 74% connected, only 26% with no-access.  In cities, there is
commonly low access in the urban core suffering poverty while the wealthy suburbs
are fully wired.
Still, people find a way to get online
In a survey of over 2000 Mississippi households,  79% said someone in the home had
used the Internet. Outside locations included school, workplaces and the local
library.  In some libraries, free internet service is the biggest draw into the building.
Among the reasons for having no access at home were cost and lack of equipment,
but the key reason seemed to be lack of understanding of the value of the Internet,
an aspect of low health literacy.  Of those without access, 46% said they didn’t need
it or were not interested.  Others, especially younger, less educated, low income
adults said they mostly go online using their smartphones.
Access in steadily increasing
A February 2011 survey found 68% of households with a connection, suggesting
significant growth in just a few months.  Some of the most rural areas seem to be
improving quickly; but the South has shown only modest improvement. The Obama
administration has directed billions of economic stimulus dollars to increase Internet
access. And some companies have just begun offering low-cost broadband connection
to families with a child who qualifies for free school lunch.
Finding reliable information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide
is intentionally focused on essential health behavior topics directly linked to pregnancy
outcomes. Some parents want to know more.
New Resources for Mothers coming to www.BeginningsGuides.com
For those who do have Internet access, and to motivate those who don’t to find a way,
the new 2014 edition of  Beginnings Pregnancy Guide includes this icon to encourage
readers to visit the new Resources for Mothers pages of www.BeginningsGuides.com 
The new section provides links to information and resources from reliable sources that
Beginnings Guides staff have reviewed and found easy to use. This reduces the need for
advanced searching and evaluation skills. We envision the new Resources for Mothers
as an easy entry into online self-directed learning about health and an opportunity for
parents to improve their health literacy.

Dunbar, J. (2012) Poverty Stretches the Digital Divide,  the Center for Public Integrity.

Beginnings Pregnancy Guide Update

The 2014 9th! edition of Beginnings Pregnancy Guide, in English and the 4th
Spanish edition are in production. Here are some of the changes to look for.
Who to call
A subtle but important revision is in who to call for information or assistance.
Previous editions have said, “... call your doctor.” Since physicians are not
always prepared or inclined to lead discussion of topics that are sensitive or
not strictly medical,  I added home visitors and sometimes doulas on topics
including breast feeding, smoking, abuse, weight gain, depressive symptoms,
conflicting advice, relationship issues, car seats, and labor pain management.
On these and similar subjects the new Beginnings says, “Talk with your doctor,
home visitor or doula.”   This supports a shift in parents’ thinking from “the
doctor takes care of my health” to ‘the doctor helps me take care of my health”.
Keys to a Healthy Baby, the health behavior messages that research links directly
to birth outcomes are modified slightly.“Do eat well” is expanded to “Do it well and
often”  since a pregnant body easily and quickly slips into starvation mode. Frequent
small meals best support fetal development.
“Do gain weight” is expanded to “Do gain weight slowly” In response to concerns
over obesity and the trend to gaining in excess of guidelines. The latest guidelines
recommend an 11 pound gain for a woman who starts pregnancy overweight.
“Do take vitamins” is expanded to “Do take vitamins everyday” to emphasize
the need for consistency to maintain a healthful level of nutrients in the body.
Early Inductions
Early term inductions of labor for vaginal birth more than doubled between
1990 and 2006 from 7.5 to 17.3%. And the percentage of later preterm C-section
deliveries increased by 46% from 23.5 to 34.3%.  A 2010 study found 44% of women
had their labor induced, often for convenience of the parent or the physician.
Those women were twice as likely to have a C-section as women who waited for
natural labor.( Ehrnethal  et al. July 2010 Ob&Gyn). In light of that trend, the
updated Pregnancy Guide’s discussion of the course of pregnancy (p46) includes a
statement that “Labor should not be induced before week 40, except for medical
reasons. The section titled  Baby’s Growth and Development, 9th month (p61)
encourages readers to exercise their health literacy skills and speak up about this
concern. “If your doctor talks to you about inducing labor, ask if you wait until
week 40.”
Other revisions
Nuchal lucency test is added to the discussion of prenatal testing.
Juice is de-emphasized in favor of water.  Juice was considered a healthful
alternative. However, with the increase in obesity, extra calories  and sugars
in juice are of concern.
Next: My favorite change. 
Reference: National Center for Health Statistics Data Brief 24, Nov 2009.

Top 4 Reasons to Promote Maternal Health Literacy

1. Health Literacy is a key determinant of health.
•Limited health literacy, measured as ability to read medical terms and
documents, is linked to riskier health choices, less participation in preventive
activities, more accidents, poor adherence to medication, more hospitalization,
increased morbidity and premature death.

• Studies using more comprehensive measures demonstrate that health
literacy has a specific direct and independent effect on self-assessed health.

• Limited health literacy in mothers is linked to increased risk of 
developmental delays and reduced participation in Early Intervention
when delays occur.

2.  Health literacy means empowerment: the capacity to make choices
and transform those choices into desired actions and outcomes.
(World Bank)

• Mothers cannot achieve their fullest health potential and nurture a healthy
competent child unless they are able to take control of those things which
determine their health.  (Ottowa Charter for Health Promotion)

3. Efforts are highly leveraged in pregnancy and early parenting

• Pregnant women exhibit readiness to learn and change well above national
norms. They are becoming healthcare decision-makers for themselves and
their families. Developing their health literacy in pregnancy can benefit entire
families across their lifetime with short and long term benefits extending to the
healthcare system, the justice and to the schools; to the public health and the

4. Mothers’ health literacy is an important factor in prevention of
noncommunicable diseases that are now the leading causes of death in
the US and globally.

• Both limited health literacy and noncommunicable disease disproportionately
affect poor, under-educated, and minority populations.

• Limited health literacy reinforces inequities. 

• Promoting maternal health literacy and empowering mothers are recognized
global health strategies for reducing the burden of noncommunicable disease
with origins in early development, and associated disparities.  
(WHO, United Nations)

Pregnancy Guide Update: Obesity a disease?

The American Medical Association House of Delegates declared obesity a disease
last month. Is this good for maternal and child health?  For public health? 
It’s not new
In 1995 the National Heart Lung and Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten years earlier, almost 30 years ago now,
NIH called prevention and treatment of obesity a national medical priority.
With 90 million Americans now officially obese, it seems few clinicians got the
Obesity prevention not a priority in maternity care
In researching issues of weight gain in pregnancy for  the update of the
Beginnings Pregnancy Guide, I found that weighing is still the only procedure in
early prenatal care that has shown any impact on outcomes. And yet it has
become uncommon for a pregnant woman to be weighed at prenatal visits or
when being admitted to a hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation will
interfere with their patient/provider relationship. Others said they do not know how
to calculate BMI. They also must not know about the many BMI calculators that will
do it for them. One can only hope that calling obesity a disease will change these
Healthy mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a mother with an excess of fat cells produces a baby
with an excess of  fat cells. So we are building obesity and the attendant health issues
into the next generation.
ACEs -Adverse childhood experiences - witnessing or experiencing interpersonal violence
is closely related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical treatment,
many such women have lost weight, and gained it right back. That’s how the lifelong
effects of ACEs were discovered.
Other mothers have said it doesn’t matter if they gain too much in pregnancy since
they are just going to get pregnant again; the weight can come off after that.
Only it rarelydoes.
Turning people into patients
Google “obesity disease”. The first thing that pops up is ad ad for weight loss surgery.
This may be more telling than official statements.
Especially when we consider the Forbes June 28 report that the AMA’s Council on Science
and Public Health, the group appointed to address the question, advised against declaring
obesity a disease. But the delegates chose ignore their own advisors.
We have to ask, what was so compelling?
Perhaps it is the implementation of the Affordable Care Act that will bring healthcare
coverage to millions of Americans previously excluded from the healthcare system.
At least a third of them are obese. Now they can be patients.
According to CDC 35.7% of Americans are obese, 49.5% of African Americans, 40% of
Mexican Americans. Rates vary widely by state. Find your state rate at
http://www.cdc.gov/obesity/data/adult.html.  Now all those people are diseased
and in need of medical treatment.
Calling obesity a disease, again, could draw attention to related health issues, but it
hasn’t in 20 years.  It could result in better maternity care, but the declaration is
unlikely to improve clinicians communication and counseling skills.  It could spark a
Kennedy-style physical fitness craze, but that entails behavior change, and the same
communication issues.  It could increase research on obesity, but NIH already has a
Strategic Plan for Obesity Research and funds nearly a billion dollars worth of studies
annually. Grants.nih.gov lists 49 obesity-related research solicitations currently open
for submission of grant applications. 
Only one thing seems certain, making obesity a disease will increase medical treatments
and costs, and revenue to AMA constituents.

Beginnings Pregnancy Guide Update: “Entertainment Ultrasound” Warning

Choose 2D, 3D or 4D.  In-studio or at your baby shower. Announce your pregnancy
with a “viewing party”. Get a video at the mall. Post it on Facebook. Select the
premium package offered by a Miami OB-GYN’s office and get a weekend discount.
The American Institute of Ultrasound Medicine, American College of Obstetrician
s and Gynecologists, American Academy of Family Physicians, March of Dimes,
US Food and Drug Administration, England’s National Institute for Health and
Clinical Excellence, the UK’s National Collaborating Centre for Women's and
Children's Health, and other national and international experts all have published
strong recommendations against non-medical use of fetal ultrasound.  The Society
of Obstetricians and Gynaecolgists of Canada calls for a complete ban on non-
medical use of fetal ultrasound. The state of Connecticut legislated a ban in 2009. 
The FDA says that creating fetal keepsake ultrasound images is “an unapproved
use of a medical device,” and those who perform ultrasonography scans “without
a physician’s order may be in violation of state or local laws or regulations.”
“You don’t need an excuse to be happy.”
Still internet ads for non-medical ultrasounds abound, complete with slogans like
this, implying you don’t need a medical reason for the “painless, relaxing procedure”.
The growing popularity of “keepsake ultrasounds” is not due to cost or access issues.
Most insurance companies pay for one or two doctor-ordered ultrasounds as part of
routine prenatal care, and commercial ultrasound is not cheap.
Prices start at $175 for the 3D in-studio option. $500 for an “ultrasound party”
at the location of your choice. The cheapest rate I saw was $75 for a basic “gender
determination” scan; it’s discounted to  $55 on Saturdays one OB-GYN’s office. These
commercial services are not regulated or standardized.
Safety Concerns
Commercial sonographers say that ultrasound is safe. I found unclear statements like:
“All research provided has been proven to be safe for expectant mothers and baby,
as long as the procedure is done by a trained professional, and no longer that one
hour intervals.”   First, we have to ask, research provided by whom? and What about
the research that was not provided?  Second, remember that no research ever proves
anything. It can only offer statistical evidence. Then, a more accurate statement is
that repeated ultrasounds have not been proven harmful. Still  the evidence has
convinced all the advisory and regulatory agencies that entertainment ultrasounds
are worrisome.
Ultrasound uses sound waves, not xrays. So radiation is not the issue. But the procedure
targets the fetus with heat and  pressure, especially prolonged, 4-D studies. New York
state legislators proposed a ban on ultrasonography for entertainment purposes, citing
data showing that 4Dl ultrasound equipment can emit eight times more energy than the
machines commonly used in medical settings. The risk of  effects on fetal development
has been demonstrated in both human and animal models, and remains, at least theoretically,
so that  the FDA concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
Additional concerns about non-medical ultrasonography include the possibility that non-
medical ultrasonography will fail to identify a problem with the baby, falsely reassuring
the patient and her family; or that a false-positive result could create unnecessary anxiety
and follow-up testing. Machines are unregulated so may not be properly calibrated or
maintained. Technicians may not be well-trained or proficient. “gender determination”
had never been an accepted use of of ultrasound technology and raises thorny ethical issues.
Medical ultrasounds are for doctors         
Here’s the problem:  In medical settings, the sonographer is commonly prohibited from
explaining ultrasound results to the patient, who must then wait for days or weeks to get the
results from the physician who ordered the scan. Family members may be barred from attending
the ultrasound appointment to avoid congestion in the radiology department. Parents may not
receive still pictures or video to take home. If they do, they still cannot send it to a friend or post
it online.  Until these disempowering practices change, parents and  sonographers  will continue
to seek a more informative,  convenient, family friendly experience. 

Check  Technician’s Credentials                      
Qualified sonographers are trained and certified. Find one, or check a technician’s credentials,

Beginnings Pregnancy Guides says, “Ultrasound is safe for you and Baby.”  [p8] That remains true.
The 2014 edition will add this statement: Many healthy pregnancies do not need ultrasound.
Extra  “keepsake" ultrasounds may be harmful.  The Registry of credentialed sonographers
will be posted on the new Mothers’  Resources page at www.BeginningsGuides.com  More on that later.

Don't Order Fetal Ultrasound Videos As Souvenirs: FDA

References:  http://www.aafp.org/afp/2005/1201/p2362.html#afp20051201p2362-b6

“Health Illiteracy” is Not a Disease

Sometimes iPhone helps too much;  so we inadvertently retweeted this,
and then the retweet was favorited: Health Illiteracy-- a disease that
also afflicts doctors...  I would not intentionally repeat this phrase. I
hope you won’t either. Here’s six reasons why.
1.  The term “health illiteracy” focuses on patients’ deficits and places
patients in a position of failure and incompetence. This approach
generates anxiety and resistance in patients and calls up their defenses.
It disempowers patients while requiring that they be active decision-makers
and participants in their care.
2.  The term “health illiteracy” equates lack of medical and healthcare
vocabulary -jargon-  and disease knowledge with illiteracy and all the
stigma that goes with it. It situates in the patient systemic problems in
healthcare  (indecipherable & conflicting information, inefficiency, high
costs, poor outcomes); so that when treatment is successful doctors get
credit, and when it’s not, patients get the blame.
3.  “Health illiteracy” is neither a disease nor an affliction.  This metaphor
further tips the power imbalance. it implies health illiteracy is a problem
that patients have and doctors need to treat or manage. It cements the
notion that patients cannot grasp doctors’ specialized knowledge or use
it for their personal benefit; so that an “appropriate health decision” is
equated to compliance. And non-compliance is framed as cognitive deficit
or irresponsibility.
4.  Here is the first definition of “disease” produced by a Google search:
“a disordered or incorrectly functioning organ, part, structure, or system
of the body resulting from the effect of genetic or developmental errors....
The metaphor adds stigma to stigma implying cognitive deficits and
disabilities, rather than underdeveloped skills, poor quality education,
inexperience with the healthcare system, or poor communication and complex,
concept dense, jargon laden, overly technical information.
5.  An “affliction” is defined as a condition of pain, suffering, or distress. Most    
adults who scored in the Basic or Below Basic levels on the  2003 National   
  Assessment of Adult Literacy reported that they read well. They are not
“afflicted”until the enter the healthcare system.
6.   The tweeted blog is titled “Screening-illiterate physicians may do more
harm than good”, which a tweeter translated to the comment that health
illiteracy afflicts doctors as well as patients.
The blog bemoans that many doctors are “functionally illiterate regarding basic
screening concepts’”  This language conflates functional  literacy with knowledge.
Functional  literacy (the 3Rs) refers to  skills used to  gain knowledge.  Lack of a
particular set of  knowledge, does not  indicate inability to read or to learn.
Conversely, “functionally illiterate” means having reading and writing skills
insufficient for ordinary practical needs. Any one who got into medical school         
can read and write.  If they do not understand screening concepts, that says
more about their educators than about their cognitive ability.  Further,         
framing lack of knowledge as functional illiteracy -  inability to gain knowledge - is as
disempowering to doctors as it is to patients. 
I agree with the blog authors’ conclusion that more attention needs to be paid to
improving physicians knowledge (not their literacy) about screening tests in order to
reduce use of ineffective tests that expose patients to potential harm -- especially

health literacy tests.
More attention also needs to be paid to increasing understanding of literacy and
health literacy.
Here’s the blog:

With few exception, childbirth is normal % healthy, but...

Of the 10 most frequently performed in-patient procedures,  5 are related to maternity 
and newborn care (2010 figures - latest available).
Bad news: the cesarean section (surgical delivery) rate continues to rise; it is up 41%
since 2004, despite global evidence that rates over 15% do more harm than good. This
is a place to cut the cost of maternity care. A cesarean section costs on average $9956
more than vaginal delivery.
Good news: Fetal monitoring, circumcision and stripping of membranes are performed
less frequently now than in 1997. The reduction in procedures returns to mothers some
control over their most significant life event, and begins to recognize that over-management
is not beneficial.
Procedure Frequency Rank       Number Performed in 2010           Increase in Frequency

Repair of obstetric                   1,292,000                                    No change

Cesarean section                      1,278,000                                    41%

Circumcision                            1,164,000                                    -31%

Artificial rupture of                  917,000                                      -5%

Fetal monitoring                      875,000                                      -23%

Maternity care costs up 41-49% since 2004 Where is the value?

The greatest opportunity to make healthcare more affordable and improve
the health status of the population is to improve the way we deliver and pay
for maternity care. Investigations of the cost of maternity and newborn care
usually report charges made by providers. But charges are routinely discounted
at widely varying rates, so the figures are not very informative re actual cost. 
A new report shows actual payments made  in 2010 (latest figures) by employer
-based commercial insurers, Medicaid and parents.
Cesarean delivery payments vary by state, by regions within states, by hospitals
within regions,  and by providers within hospitals, so vaginal birth and cesarean
(surgical) delivery are reported separately. A summary of findings in the table
below suggests where to focus advocacy efforts.

Item                  Employer Insurance +        Public Insurance
Vaginal              Out of pocket                    Medicaid
Average Total
CHARGES                      $                                         
Vaginal                         32,093                  29,800                                                                                  
Cesarean                      57,125                  50,374
Average Total
Vaginal                        18,329 + 2244         9,131                   
Cesarean                      27,860 + 2669        13,590
Prenatal Care
Vaginal                        3,180  (25%)           2,405 (39%)
Cesarean                     3,580  (21%)           2,859 (36%)
Maternal Care
in hospital
Vaginal                        9,048 (72%)            3,347 (55%)
Cesarean                     12,739 (76%)          4655 (58%)

Newborn Care
in hospital +
3mo postpartum
Vaginal                        5,809 + 558           3,014
Cesarean                     11,193 + 721         5,607
Vaginal                       30,875 + 1241        13,875
Cesarean                    45,496 + 1351        19,971
Cesarean delivery costs are 50% greater than vaginal birth for all payers. 
And cesarean delivery payments by commercial insurers increased 41%
between 2004 and 2010. In addition, parents’ out-of-pocket costs increased
The best outcomes for women and babies appear to occur with cesarean
section rates of 5% to 10%. Rates above 15% seem to do more harm than
good (Althabe and Belizan 2006) Despite the evidence and the costs, the
US cesarean rate for 2010 was 32.8%.
The table suggests one explanation for the high cesarean rate is that surgical
birth is more lucrative than “the regular way”.  Commercial payers paid
clinicians an extra $1464, and paid hospitals an extra $7518 for cesarean
vs vaginal birth. Those incentives are hard to ignore.
Further, the table shows that 70-84% of all maternity payments went to
in-patient care. But the vast majority of mothers and newborns are healthy
and the vast majority of births are routine.  Prenatal care and support 
have been shown to reduce  preterm birth, failure to thrive, and other
factors that land babies in Neonatal Intensive Care Units where costs were 3.7
to 5.6 times those for other babies. More investment in prenatal care and support
would reduce the need for  cesarean, and could help re-align financial incentives.
Truven Health Analytics (2013) The Cost of Having a Baby in the United States.
Childbirth Connection, Catalyst for Payment Reform,Center for Healthcare Quality
and Payment Reform. 
Althabe F, Belizan JF. Caesarean section: The paradox. The Lancet 2006;368:1472-3.


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