Right Questions about Anti-Depressants

Many years ago my husband and I were the proprietors of a small rural motel near a ski mountain. We rented rooms and studio apartments to tourists on the weekends and some of the studios were rented by the week to seasonal workers or local people who appreciated a small, affordable apartment. I would sometimes ask the residents, "How is your truck running?", which was my proxy question for "How are YOU doing?".

 I recently had a similar conversation with a family member.

"How is your car running?"

"Great!" he said, "It has 219,000 miles and it's running well."

Good! If he had responded, "Oh, I just had an unexpected repair bill of $1700 but I cannot afford a new car right now", it might have indicated he is stressed about finances. Complaining about all the small things that can go wrong with a 10-year-old-car would have provided a different insight.

Are we asking the right questions to know how people are doing?

Health providers may use a depression screening tool and then refer to an algorithm to determine whether the patient should be prescribed an anti-depressant, or SSRI (selective serotonin reuptake inhibitor) drug. The clinician might also make a referral for the patient to see a mental health provider, who would spend more time asking questions through a series of Cognitive Behavioral Therapy sessions or CBT, but taking a pill is more convenient, economical, and private than more appointments. Business Insider reported in 2016 that more than two-thirds of Americans taking anti-depressants have not had an appointment with a mental health specialist in the last 12 months.

The long term effects of using SSRI's are being studied. In 2014, the New Zealand Mental Health Foundation asked more than 1800 people how they felt when they were taking anti-depressants in an on-line questionnaire. Eighty-two percent said the drugs reduced their depression, but many reported side effects of sexual dysfunction (62%) and feeling emotionally numb (60%).

The World Health Organization listed the rate of depression reported around the world pretty consistently between four and six percent of all adults, with some higher exceptions in areas of conflict (e.g., Ukraine) and lower exceptions (South Pacific Islands). The rate of use of anti-depressants, however, varies greatly as shown in Table 1:

Table 1

Anti-depressants may also be prescribed for non-depression diagnoses, such as anxiety, sleeplessness, and neuropathic pain. The use of anti-depressants may depend on wealth, health coverage, and availability of treatment. Not surprisingly, anti-depressants tend to be more prescribed in countries with fewer mental health providers, as seen in Table 2:

Table 2

What are reasons for varied rates of use of anti-depressants? Here are some insights for the three highest consumers of anti-depressants.

Australia

The Australian government recognizes a key barrier to accessing services is the scarcity of mental health professionals. In November 2017, access to mental health services was expanded to include telehealth consultations for people in regional, rural, and remote Australia.

The telehealth consultations are a psychological therapy service that is delivered via video conference where both a visual and audio link have been established between a patient and their treating health professional. Telehealth services can be delivered by psychologists, social workers, and occupational therapists. Telehealth removes the travel barrier for patients and clinicians and will be discussed in a later blog post.

United States

In 2017, Time Magazine reported that about eighty percent of anti-depressant patients in the US are receiving care from someone other than a psychiatrist. The article also said during the last decade the number of mental health professionals in the US has been steadily declining due to aging of the current workforce, low rates of reimbursement, burnout and burdensome documentation requirements. The World Health Organization reports the number of mental health providers per capita in the US is now below economically-devastated Greece.

Or perhaps the US patient asked for a drug they saw advertised on television or in a magazine.  Prohibited by thirty-three OECD (Organization for Economic Co-operation and Development) countries, the US and New Zealand both allow pharmaceutical companies' Direct-to-Consumer Advertising (DTCA). Almost all DTCA is for patented or branded medications. In August 2014, The New Zealand Medical Journal reported that American pharmaceutical companies spent more than US$4 billion in Direct-to-Consumer Advertising, more than ten times the entire Food and Drug Administration annual budget for evaluation of new drugs. And this cost is paid by whom? 

Iceland

Multiple sources in Iceland attribute the high rate of anti-depressants to limited access to alternative treatment like psychotherapy. A 2004 study by the National Institutes of Health studied Iceland during a period of rising use of anti-depressants from 1975 to 2000 when the daily defined doses per 1000 inhabitants climbed from 8.4 to 72.7. The study was unable to see a reduction in the suicide rate or disability due to depression during this period despite the eight-fold increase in use of anti-depressants and concluded, "The dramatic increase in the sales of anti-depressants has not had any marked impact on the selected public health measures [suicide and disability-adjusted life years]. Obviously, better treatment for depressive disorders is still needed in order to reduce the burden caused by them."

The right questions, asked by the right people, at the right time

Cognitive Behavioral Therapy can work as well or better than medication to treat mild or moderate depression and it can also help with more severe cases if the therapist is highly skilled. It is based on the idea that problems are not caused by situation themselves, but rather how we interpret them, which can then affect thoughts, feelings and actions. CBT aims to break negative cycles by identifying unhelpful ways of reacting and replacing them with more useful or realistic ones. 

The CBT approach is not new. In fact, it reflects the ancient Greek philosopher, Epictectus, who famously said, "Men are disturbed not by events but by their opinion about events." Epictectus was a Stoic philosopher in the first century AD who grew up as a slave in the Roman Empire, so he was keenly aware of how little we control in life. He divided events into two categories: what can be controlled and what cannot be controlled, and suggested managing only what was within one's control, since problems begin when we try to control what is not within our control. He optimistically felt that we can all change our habits with practice.

Giving an anti-depressant is treating a symptom or effect, not the cause. Without accompaniment of a mental health provider, it is like putting the ambulance at the bottom of the cliff. Access to mental health providers is needed for better long term care.

PS: Happy 2018 International Stoic Week, which begins Monday, 1 October. 

Hear Around the World

Jesse and Louie were our next door neighbors when I was growing up. They were retired and from the generation who had lived through World War II. Jesse spent her days as the consummate homemaker and Louie puttered around their property keeping everything in working order. Jesse was in constant motion with crafts or baking pies and simultaneously provided unending commentary on what she and Louie were doing at the moment. Louie was a bit more reserved. He did not say much and often remarked that Jesse said enough for both of them. 
Many years later, I wonder if he had been withdrawn from conversations due to his hearing difficulties.

Isolation is the new smoking in terms of a risk factor for illness and death. Studies are showing socializing is more important than regular exercise or healthy diet. Hearing is key to socializing and lack of hearing can be a factor for physical exhaustion, forgetfulness, and depression.

Where is hearing loss?

Most countries report similar levels of hearing loss between 9 - 11 percent of the total population.

Countries report different results in managing it, however:

What do hearing aids cost?

Fortunately, technology has provided options for hearing restoration. But, at what price?

New Zealand

Hearing tests are free. In 2015, the Ministry of Health paid for 24,500 hearing aids and reported the average cost of a single hearing aid was $2,233. The government subsidized $511, leaving $1,722 ($1,150 US) to be paid out-of-pocket. Additionally, the Accident Compensation Corporation (ACC) government program contributes toward the cost of hearing aids for people suffering hearing loss due to injury from an accident, medical misadventure, or industrial noise. The amounts vary depending on the severity of hearing loss from $935 to $1,833 per hearing aid. The ACC will also contribute toward second opinions, cost of fittings and ear molds, and repairs after expiration of the two-year warranty.

United States

In the US, a person without insurance might pay $270 for an exam by an audiologist. I would have had a $20 co-pay thanks to my "excellent" insurance which my employer and I paid $1,200 / month for my husband and myself.
A US friend reports finding good hearing aids at Costco ranging between $1,200 - $5,000 per hearing aid. Another friend opted for high-end hearing aids and paid $7,000 for two, which includes a lifetime guarantee and offers quarterly cleaning and checkups. Both friends were eligible for Medicare, which offers a bottom-of-the-line hearing aid sent through the mail without any fittings or follow-up.
For the most part, Medicare does not cover cost of hearing aids nor do most insurance plans, with the exception of some plans for children, federal workers, and veterans. A few plans, including some from Medicare Advantage, offer partial coverage or discounts. Residents of some states (Arkansas, New Hampshire, and Rhode Island) may also be eligible for hearing aid coverage since insurers are required to provide coverage for adults. New Hampshire insurance companies are required to cover the cost of no less than $1,500 per hearing aid once every five years. Rhode Island requires individual and group insurance policies to provide $700 for each hearing aid every three years. In Arkansas, insurance companies are required to offer coverage to employers. If the company chooses this option, the insurance company must provide coverage of no less than $1,400 per hearing aid every three years.

Europe

European countries which provide a subsidy for hearing aids experience higher hearing aid use:

• Norway - the maximum public subsidy is 5,400 Nkr per hearing aid ($788 US, $1,180 NZD)
• Switzerland - Like New Zealand, Switzerland has a two-tier subsidy, paying 630-840 CHF ($633-845 US, $948-1,265 NZD) per hearing aid, with the lower range applicable to those with age-related hearing loss and the higher range applicable to hearing loss affecting ability to work.
• UK - hearing aids, tests, and fittings are free. NHS funds behind-the-ear and receiver-in-the-ear types. Private clinics and other newer products are available, but the NHS reports that 84% of hearing aids were obtained through public funding. HOWEVER, in 2015, some districts began rationing hearing aids by only providing one hearing aid for those who needed two, and starting in October 2018, some districts such as North Staffordshire will no longer provide hearing aids to adults with mild to moderate hearing loss.

Norway and Britain reported the waiting list for a publicly funded appointment can be several months. For those who choose to go to a private dispenser, virtually no waiting list is involved.

Here are the results:

Hearing is a gift. How different life would be without music, the sounds of birds, the ocean, or the voices and laughter of family and friends. With growing distain for loud restaurants and parties, before following Louie too far into isolation, it's time to have a hearing test.

Immunizations

IMAGINE an airborne flu virus so virulent that it was three times as contagious as our current influenza viruses. Out of every thousand cases, there would be one or two deaths in the developed world despite access to the best care, and 60-100 deaths where the victims suffered from malnutrition or did not have access to healthcare. There would be hundreds of millions of cases and over a million deaths per year worldwide, about 80 percent of them would be children from all countries and all levels of society. Of those who survived, about one in 20 would develop pneumonia. Some survivors would be blind or deaf. 

Now imagine our brilliant researchers develop a vaccine that protects you and your children from this horrible scourge with a 97% assurance. Would you not want to protect yourself and loved ones?

I have just described Measles.

When my infant son was due for his first immunization, I was given a pamphlet that said there was 1 in 300,000 chance of an adverse reaction. I remember discussing with his godmother that I didn't like those odds. However, he was a healthy baby and his father and I both survived various immunizations, so I took him for his jabs and held him while he cried. 

This was years before the debacle of Andrew Wakefield and his 1998 article published in The Lancet claiming links to autism from an immunization vaccine. 

In this original research paper (Lancet 1998;351[9103]:637-41), Wakefield and 12 coauthors claimed to have investigated "a consecutive series" of 12 children referred to the Royal Free Hospital and School of Medicine and parents of eight of those 12 children associated their loss of acquired skills, including language, with the Measles, Mumps Rubella (MMR) vaccine. The authors concluded that "possible environmental triggers" (i.e. the vaccine) were associated with the onset of both gastrointestinal disease and developmental regression.

TWELVE YEARS LATER, Britain's General Medical Council (GMC) ruled in January, 2010, the 12 children that Wakefield studied were carefully selected and some of Wakefield's research was funded by lawyers acting for parents who were involved in lawsuits against vaccine manufacturers. 

A few weeks after the GMC ruling (2 Feb 2010), The Lancet apologetically said that "several elements are incorrect, contrary to the findings of an earlier investigation."

Three months after The Lancet retraction, Wakefield was removed from the UK Medical Register for unethical behavior, misconduct, and fraud, with a statement identifying deliberate falsification in the research published in The Lancet, and was thereby barred from practicing medicine in the UK. 

In the following year, articles by Brian Deer in The British Medical Journal described Wakefield's work as "an elaborate fraud" and claimed that Wakefield had planned to launch a venture that would profit from new medical tests and litigation-driven testing as a result of the MMR vaccination scare.

So where is Wakefield today?

Unable to practice medicine in the UK, the disgraced doctor has re-invented himself in Trump's anti-vax America. Based out of Austin Texas, he aims to advance his agenda and he is making progress. Emboldened by Trump's personal endorsement, he speaks at anti-vaccine rallies at the Texas state capitol building, and he holds screenings of his film, "Vaxxed: From Cover-Up to Catastrophe", throughout the state. Texas is also home to Texans for Vaccine Change, a Political Action Committee (PAC) that throws its support behind politicians who share their donors' views towards vaccinations. Non-medical vaccine exemptions have increased in Texas since 2003, when the state enacted some of the loosest vaccine exemption laws in the US. Parents can opt out of public school vaccine requirements if it goes against their conscientious beliefs as a result of the 2003 law. Today, the Waldorf School in Wakefield's hometown of Austin TX has an immunization exemption rate of more than 40 percent.

Texas is not a lone star in Wakefield's wake. It is only one of 19 states in the US that does not have a law requiring people to get vaccinations.

Prior to a visit from Wakefield in 2008, a Somali-American community in Minnesota had the highest rates of vaccinations against measles in the entire state. Last year, the community had an outbreak of Measles which was the highest the state had seen in years. When questioned by The Washington Post regarding the Minnesota outbreak, Wakefield said he was simply providing information about vaccines and autism. "The Somalis had decided themselves they were particularly concerned. I was responding to that," he said. "I don't feel responsible at all."

California

California's response to the "Disney Outbreak" illustrates how some regions are approaching this public health concern differently. In January, 2015, 84 people were diagnosed with Measles and most had visited Disneyland or Disney California Adventure in mid-December or were in contact with someone who had visited the theme park. As a result California outlawed "personal belief" exemptions from vaccination requirements for schoolchildren, and subsequently vaccination rates went up. Those familiar with the US know this is a significant departure from California's liberal reputation as a protector of individuals' rights.

"Measles is not dangerous", said Robert "Dr. Bob" Sears, MD, a California pediatrician, in his social media post. "Ask any grandma or grandpa (well, older ones anyway), and they'll say, 'Measles? So what? We all had it. It's like chicken pox.'" He is obviously referring to those who survived Measles in childhood. Those who did not survive would have a different answer.

Europe

In Europe, 2017 was a bad year for Measles. According to the European Centre for Disease Prevention and Control, most immunization rates in affected areas have fallen below the critical 95 percent threshold due to skepticism about the vaccine. After Romania, the second highest outbreak in 2017 was in Italy, which had 5,006 cases and three deaths; 88 percent of those people had not been vaccinated and 7 percent did not receive the recommended dose. Last year's Measles outbreaks have led Italy, Germany, and France to pass laws that require parents to vaccinate their children or consult a doctor about doing so. Italy and Germany now impose fines of $600 - $3000 for failing to comply.

REGARDLESS OF WHERE YOU ARE IN THE WORLD:

• Measles is highly contagious and is spread through coughing and sneezing. Those confirmed to have the disease are infectious from five days before the onset of the rash to five days after the rash starts. The rash usually first appears on the face, then moves down to the chest and arms. Ninety to ninety-five percent of those breathing the same air will be exposed. By comparison, flu transmission affects thirty to fifty percent of those breathing the same air.
• Measles was declared eliminated from the United States in 2000. Likely the shift working in the Emergency Department this weekend in any of the developed countries have not seen a confirmed case. It's easily missed in the best of hospitals since its early symptoms include a dry cough, runny nose, temperature of more than 38.5C (101.3 F) and feeling very unwell.
• Measles vaccine has led to a huge drop in global deaths from the disease. In the 1980s, Measles killed 2.6 million a year. In 2016, for the first time in recorded history, deaths fell below 100,000. 
• Credit to the Church of Latter Day Saints for its strong pro-vaccine position. In addition to advising its members to get immunizations, the Church has donated millions of dollars to vaccinate children in over 40 countries since 2003.
• People are considered immune if they have had two doses of the MMR vaccine, have had Measles previously, or were born before 1969.
• People should stay in isolation while they're infectious - this means staying home from school or work and not having contact with unimmunized people.
• If you have children in school, ask about exemption rates. If they are not at or below the national average, consider changing schools. If you live in Austin Texas, good luck!

CL=Confidence Limit.

The shaded area represents the number of deaths prevented as a result of the vaccine. The cumulative total for the period 2000-2016 is 20.4 million. 

Prescription for High Cost of Medications

Last year I had the privilege of working with the Ralph Lauren Center for Cancer Care in New York City. They provide care for not only the poor with no insurance, but also many under-insured. Their patients include hotel workers, cab drivers, and other working people who were struggling to make ends meet even before being confronted with a serious illness.

An article published in 2016 by the Kaiser Foundation and the New York Times reported one in five working age Americans with health insurance said they had problems paying medical bills. 63% reported using all or most of their savings and 42% took an extra job or worked more hours to pay their medical bills. This is also seen on crowd-sourcing sites to raise funds. A search on gofundme.com showed nearly 43,000 causes for "medications US". To help readers outside the US understand this situation, most say something like this:

"C is a precocious 7-year-old who has recently been diagnosed with Type 1 Diabetes. On a road trip home from visiting family in Atlanta she became very ill and the family was forced to stopped at the nearest hospital The hospital was not equipped to take care of a small child and her health was quickly declining ... so she had to be air-lifted to a facility with a PICU where she spent 7 days in the hospital recovering from a severe Diabetic Ketoacidosis. Although having medical insurance, the emergency transportation billed an additional $39,000 and her hospital stay was over $20,000. C is being raised by her single mother who is an elementary school teacher and the cost of overwhelming medical bills, co-pays, and daily medications has put a tremendous financial strain on her mother and everyone who helps support her."

Diabetes is a particularly burdensome chronic disease and it is costly to manage. Metformin is a common treatment for Type 2 Diabetes, currently used by over 14 million Americans.

Cost of Metformin for 100 500mg tablets:
US (Pharmacy Checker): $21.43, with coupon and discount club to reduce cost, otherwise about $48.
NZ (local pharmacy):        $5.00 (NZ) or $3.50 (US) for New Zealand residents

These costs alone may not feel particularly burdensome, but the stress of paying for the medications, test kits, and doctor visits is increased with the complexity of insurance, discount clubs and coupons, co-pays and deductibles. 

Managing is costly and stressful, but not managing costs more. Unmanaged, diabetes progression can lead to blindness, kidney failure, and limb amputations. 

"Type 2 diabetes is a major burden for the payer", began an article from the National Institutes of Health published in October 2016. Wow. How about major burden for the patient?! In spite of this dodgy beginning, the article had redeeming value in revealing the cost-effectiveness of medication adherence and lifestyle interventions. Type 2 diabetes is largely preventable with physical activity and a healthy diet. Consider the following comparisons: 

Japan

Not surprising Japan has a lower rate of diabetes, as they also have low rates of obesity and other related illnesses, and they enjoy a longer life expectancy than most countries.

I asked a friend in Japan about his children's exercise programs. He replied the public elementary school in Tokyo where his two daughters attend has a regular 45-minute physical exercise program 3 times/week. In addition, his daughters enjoy swimming and rhythmic sportive gymnastics so likely they are meeting the World Health Organization (WHO) recommendation that children 5-17 engage in 60 minutes of moderate to vigorous activity DAILY. His son attends a private kindergarten, which in addition to daily typical play activity like running in a garden, jumping rope, etc., also has an outsourced training coach for a 60-minute physical exercise program twice/ month. Outside of school, his son enjoys swimming and tennis, so likely he is meeting the WHO recommended daily activity level, too. 

United States

US national recommendations on physical activity for children are consistent with the WHO, but only one state is meeting this.

More typical is South Carolina, which mandates at least 60 minutes of physical education per week in grades K-5, but it does not require daily recess. The state also mandates that high schools provide physical education to students (no time limit given), but there is no requirement for middle school/junior high schools. Predictably, South Carolina has one of the higher rates of obesity. According to the State of Obesity Report published in 2016 by the Robert Wood Johnson Foundation, 32.9% of South Carolina children are overweight or obese. 

Another example: A family member's first grader in Colorado has two 20-minute recess periods per day, plus a regular 40-minute physical education class three times per week. When the family moved there recently from Texas, they noticed fewer overweight kids in the school, and the State of Obesity study supports their observation: Rates of overweight and obese children in Colorado and Texas are 27.2% and 33.3%, respectively. 

South Carolina and Texas are not the worst performing states. That would be Tennessee where 37.7% of children are overweight or obese. The best performers are Utah and Oregon, which are not exactly impressive with rates of 19.2% and 20.3%, respectively.  Coincidentally, Oregon was the only state that met national recommendations for weekly time in physical education in 2016.

If one-third of children were failing math, there would be massive reform in the math curriculum. One-third of US children are failing to be physically fit, so perhaps it's time to reform the physical education and activity curriculum. 

New Zealand

The disparity between New Zealand and Australia illustrated in the above data from the World Bank is believed to be attributed to the difference in their minority populations which have three times the incidence of obesity and diabetes: 

                                       % Māori (NZ) /               % Pacific

                                     Aborigine (AUS)                Islander

    New Zealand                 15%                                   7%

    Australia                          3%                                  <1%

Whānau Pakari Programme

To address this disparity, the Whānau Pakari Programme conducted home visits with a comprehensive assessment (medical, dietary, physical and psychology screen) and advice for 239 overweight adolescents in the lowest quintile of a rural community, which was also 45% Māori and 3% Pacific. Weekly, family-based group sessions to support healthy lifestyle changes included cooking classes, virtual supermarket tours, growing vegetables, sports and physical activity, and psychology sessions. Did this make a difference?

Baseline Mean BMI Standard Deviation Score (SDS) was 3.12 (standard deviation =0.60, range 1.52 - 5.34). The 138 participants who completed the 12-month program averaged a decrease of 0.18 SDS, and the 22 participants who attended at least 70% of the sessions averaged a decrease of 0.22 SDS, moving some out of the obese BMI range and into the overweight or normal weight ranges. Will they all stay at a healthy weight for their entire lives? Not likely, but this is a start in breaking the legacy of obesity. 

New Zealand is also addressing obesity and promoting healthy lifestyles for all with their "Green Prescription" program. If a patient wants ongoing support to increase their physical activity and improve nutrition, the GP or practice nurse provides the patient with a Green Prescription (GRx). The script is forwarded to the nearest GRx provider who encourages the patient to become more active through:

• monthly telephone calls for 3-4 months or
• face to face meetings for 3-4 months or
• group support in a community setting for 3-6 months.

Face-to-face meetings are free and normally held in a sports complex setting where the patient is offered reduced rates to join other programs.

Cost

Programs and interventions have costs. The alternative, doing nothing, also has a cost. The US Center for Disease Control (CDC) projects the healthcare costs of an obese person to be 42% higher than a person of normal weight. Applying this for New Zealand, where the annual healthcare cost per person is about $4000 per year and the Ministry of Health expects that cost to rise 5% annually over the next 40 years:

How to finance healthy weight initiatives? The Sugary Drink Tax introduced in Philadelphia (population 1.6 million) in January 2017 raised $79 million its first year by taxing 1.5 cents per ounce of sugar-sweetened drinks. Perhaps some of this tax money will pay for physical activity programs.

The Sugary Drink Tax is being debated in New Zealand and many regions around the world. Sanctions work. The US federal cigarette tax was hotly contested when it was doubled in the 1980’s, but most now agree it has achieved the desired result of reducing smoking. Public smoking bans and anti-smoking education financed by the Master Settlement Agreement with tobacco companies in the 1990's also helped. Taxes engender better choices, but need to be complemented with public health education and changes in systems which have contributed to the problem such as school physical activity programs. 

Having a Baby

The concept of Hauora well-being is a Māori philosophy of health unique to New Zealand. It is recognised by the World Health Organisation and encompasses four dimensions of health:

Taha tinana - Physical well-being
The physical body, its growth, development, ability to move, and caring for it.

Taha hinengaro - Mental and emotional well-being
Coherent thinking processes and constructive responses, acknowledging and expressing thoughts and feelings

Taha whanau - Social well-being
Relationships with family, friends,and others; social support and feelings of belonging, compassion, and caring.

Taha wairua - Spiritual well-being
The values and beliefs that determine the way people live, the search for meaning and purpose in life, and personal identity and self-awareness. For some, spiritual well-being is linked to a particular religion; for others, it is not.

Each of these four dimensions of hauora is evident in policies and cultural attitudes about childbirth. I asked several new mothers in New Zealand about their prenatal, antenatal, and postnatal experiences. Here are descriptions from two of them:

Experiences 
Prenatal visits 
NZ New Mother #1: Initially I visited the midwife monthly, then every fortnight, then weekly in the last month before my due date. I have a friend in the US who was pregnant at the
same time and this was a sharp contrast to her experience. She said the weigh-ins always
gave her stress and the constant measuring, testing and checking gave her more anxiety
than reassurance, even though both our babies were born healthy. When I asked my
midwife why I wasn’t having any weight checks, more scans, and general poking and
prodding, she said she was more concerned about my mental and emotional well-being and
preparedness for childbirth and motherhood, so these checks were only performed if there
was a problem, such as swelling/water retention.

NZ New Mother #2: My visits with the midwife were initially monthly, then got more
frequent as I got closer to due date. Every visit I did the pee-on-the-stick test and I had blood tests to follow almost all of the midwife appointments. I had quite a few scans, maybe 9 in total.

Childbirth experience
NZ New Mother #1: I originally planned for a home birth, but after being in labour at home
for more than 55 hours and not dialating past 5 cm we decided to escalate and go to the
hospital, where I continued labouring in the pool for 5 hours, and then ultimately delivered
via C-section after the baby began showing signs of distress. The midwife was reluctant to
move sooner, trying to respect my wishes to let labour progress naturally. In retrospect,
advice I would give to other pregnant women would be to discuss this and other specific
scenarios in advance with your midwife to have clarity about preferences and when to
escalate. The midwife probably could have advised discussing options earlier in the process
and been a little more decisive once I clearly was too worn out to think straight. The csection
went very well. The post-op care I received was in an outdated room, but the nurses,
midwives, and surgeons at the hospital were all helpful, caring and attentive during my
three day stay.

Blogger's Note: This birthing experience appears to have been an outlier. NZ midwives said active labor for a first birth usually averages 18 hours, which is consistent with US experiences.

NZ New Mother #2: I wanted a water birth, however I had been diagnosed with
preeclampsia the night before going into labour so we were expecting complications.

I ended up having an easy and short first delivery with no complications.

Postnatal follow-up
NZ New Mother #1: This was my first baby and I do not have any family in the area, so the
midwife was really helpful to me with managing a brand-new infant, breast-feeding, eating
right, and coping with post-partum stress. She visited us at home every day for the first
week, then once/week for five weeks. After that, I was referred to a home health provider,
who sends a registered nurse to do check-ups, developmental measurements, and give my
baby immunization shots, which was a lot better than travelling with a newborn to a clinic or
doctor’s office.
NZ New Mother #2: Follow up care from midwife was amazing.... just wish I could have had
her longer than the 6 weeks! She visited me at home every other day when I got home. My
midwife sent me back to the hospital due to extremely high blood pressure at one point, so
the 1st week home she came every 2nd or 3rd day, then week 2 she came to our home
twice and called twice to make sure I was ok with blood pressure then her visits were
weekly for the last 4 weeks.

Costs 
NZ New Mother #1: All costs were covered for the baby and myself, with the exception of
the prescriptions for post-cesarean pain medication and laxatives ($25 in total). I decided to
do acupuncture in the weeks leading up to labour to help with the stress, persistent nausea
and thinning my cervix and these six appointments cost $390 in total. I also paid out-of pocket for prenatal vitamins ($270 in total) rather than receiving prescriptions for iodine,
iron, and folic acid.
NZ New Mother #2: All costs were covered, except for the scans, which were $45/each, so I paid $405.

The cost of having a baby in New Zealand is free for New Zealand residents. Women may be charged for a negative urine pregnancy test, additional room services provided by a maternity facility or an extended stay in a maternity facility, some tests in a private laboratory, ultrasound scans and antenatal classes. According to the NZ Ministry of Health, the vast majority of women (96%, 2014) give birth in hospitals or associated birth centres (86% and 10%, respectively). Most choose a midwife for their lead maternity carer (94%) versus having an obstetrician/general practictioner (6%), which costs additionally between $3000-4000. Women who are not residents are asked to provide a bond (NZ$ 9000, US$6300) for their maternity care.

The costs of having a baby in the US varies widely, depending on geography and insurance. The best source of costs of having a baby was a study by Truven Analytics, published in January 2013 using 2010 claims data: Average total commercial insurer payments for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively. Medicaid payments for all maternal and newborn care involving vaginal and cesarean childbirths were $9,131 and $13,590, respectively.

The Truven study noted these amounts paid by insurers represent part of the total cost, as the insurer pays part of the bill and the new family pays part of the bill. According to National Conference of State Legislators (www.ncsl.org), insurance premiums averaged $18,764 for family coverage in 2017, with the family usually paying about $5,714 and their employer picking up the rest. In addition to their insurance premiums, women with commercial insurance typically paid about 10-12% of the total maternity care cost out-of-pocket (about $2000-3000). Women with Medicaid insurance typically paid about 1-2% of the cost (about $90-260). Also note the Truven study is a little dated. A US government website, www.cms.gov, reports that amounts for maternity care increased about 7% from 2010 - 2016. 

The vast majority of US babies are delivered by physicians. The US National Center for Health Statistics (2014) reported only 8.3% of US women had their babies delivered by certified nurse-midwives (CNMs) and certified midwives (CMs). Similar to their New Zealand counterparts, these midwives delivered in hospitals (94.3%), birth centres (3%), and homes (2.7%).

The midwife vs. physician-led maternity care might be part of this story, so I looked at rates of midwife-attended births in countries experiencing favorable outcomes in maternal mortality (deaths per 100,000 live births) and neonatal mortality (deaths per 1,000 live births). In Norway, Sweden, and Denmark, the rate of physician-attended births is about 1 out of 4, but nearly all (>95%) experience some midwife care. 

The countries with successful midwifery programmes have high standards on training and guidelines. The US midwives are regulated by state, resulting in high variability of standards and outcomes.

Not discussed here are the financial maternity/parental leave benefits during the baby’s first year offered in New Zealand, Canada, and other countries where there is societal value in parents having more than 6 weeks to be with their new babies. After controlling costs, the US might figure out how to help parents spend more time with their children.