Low budgets constrain and high budgets stimulate choices. In high-income countries, this economic reality may lead to overuse of healthcare services and pose unnecessary risks for mothers and infants. Options for improvement can be created at different levels of healthcare systems. Pregnancy provides an effective opportunity to profile maternal risks and represents a vulnerable but potentially modifiable period from prenatal life to adulthood. In response to system-inherent false incentives, professional responsibility requires obstetricians to strive to improve the future health of families and their offspring despite disincentives for doing so. This chapter addresses professionally responsible resource management in obstetrics and identifies implications for patients, care givers, communities, policy makers, and academic faculties.
Highlights
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Health literacy of patients, physicians and health care managers is essential for the future of maternal-fetal medicine.
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Research and improvement statistics should be implied into daily practice.
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Postgraduate training should be an issue of concern stimulating lifelong curiosity and learning.
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Since high budgets may lead to overuse and even harm, health care reforms in maternal-fetal medicine should follow the Triple Aim to improve patient satisfaction, health of society and to reduce costs.
“Perfection of means and confusion of goals seem to characterize our age. Even if only a small part of mankind sincerely and passionately strives for safety, welfare and the free development of talents their superiority will prove itself in the long run.” (Albert Einstein)
Introduction
Substantive justice requires that medical needs and resources are reasonably and fairly balanced . Low-resource countries suffer from limited access to healthcare or minimal technology . Their under-fulfilled needs should increase our concerns that in high-resource countries, patients are exposed to overuse or misuse of care . Ethical concepts with a global perspective are helpful but not enough . Worldwide, family care must be supplemented with affordable interventions that are implemented with political accountability .
In maternal-fetal medicine (MFM), we care for at least two patients. This clinical ethical complexity creates challenges about whether procedures can be adequately justified on the basis of medical efficacy, safety, and costs. Fetal and neonatal patients cannot ask for nor refuse treatments, and neither children nor mothers control economic resources . Associations between pregnancy, diseases, interventions, and long-term outcome of mother and child are multifactorial. To understand and responsibly manage these associations and the interplay among physicians, healthcare institutions, research, education, and other stakeholders, transparency is essential.
Physicians should not put their own economic interests above their patients’ interest . After being offered a grant for a medical business program in the United States (US), the author of this article rejected a relationship with a prestigious campus because of its primary focus on business and administrative interests. Professional responsibility and economic interests can also clash during daily clinical life. Some obstetricians might have better management skills than the new generation of business managers and controllers. However, the primary motivation of obstetricians as healthcare professionals is to reduce suffering and as researchers is to advance scientific discovery and its clinical application.
This article contains subjectively selected issues and leaves open questions. It is not meant to stimulate the innocent reader to float like a dead fish within a stream that is being increasingly polluted by self-defense and commerce but rather to reach an inflection point and swim like a salmon before reproduction toward the academic fountains of our specialty. Multicultural experience helps upstream swimmers against backflow and turbulence, to balance strengths and constraints, and to put costs into proper professional perspective.
A brief review of economic analysis in the clinical setting
Although the nomenclature of economic analysis can seem remote from clinical practice, to ignore it would be a mistake. Deriving from Latin “surgere” (to rise), resource symbolizes inner strength. Sometimes, we are left to our own resources. After productivity studies in the Hawthorne Company, Mayo concluded that employees are far more motivated by relational factors than by monetary rewards or work environment . Developments in organizational behavior claimed legitimacy for Human Resource Management (HR). The Chartered Institute of Personnel & Development and societies for HR were founded. The expression HR can be abused, as by Stalin, who acknowledged its importance but applied brutality, secrecy, and ambiguity . In healthcare institutions, HR minimizes costs by acquiring appropriate staff and providing training and maintenance of competency. Engaged and fulfilled rather than abused healthcare workers and physicians help optimize the patient experience.
Cost-effectiveness analyses (CEAs) were used by farmers to measure productivity , and its use has become popular for many other applications. The CEA guide of the World Health Organization (WHO) stresses that CEA is only one input for the use of resources; interventions should also address inequalities . The ethical principle of justice supports the concept of equity, which is the absence of avoidable or remediable differences. Life losses are calculated as years of potential life lost, estimating the number of years a person would have lived without premature death. Cost-benefit analysis (CBA) assesses the economic value of beneficial outcomes against the cost of achieving them. CEA and CBA have obvious clinical applications. It is therefore of interest that the number of obstetric publications with the Mesh-terms CBA versus CEA is less than 10%.
The burden of disease measures mortality and disability-adjusted life years (DALYs) . Although societies are severely affected by maternal mortality, the correlation with DALYs is problematic . Economic assumptions by cost/DALY as used in low-income countries cannot be generalized because human resources (e.g., availability of obstetricians) play a role. For example, costs/DALY by providing Cesareans for obstructed labor ranged from $251 in Madagascar to $3,462 in Oman . With respect to unjustified maternal or neonatal death, the use of CEA sounds harsh because such outcomes are professionally unacceptable.
The concept of quality-adjusted life year (QALY), where one QALY equates to 1 year in perfect health, has been more often used in high-income countries, although its use for selective adjustment has been criticized . The health-related benefits accrued over a woman’s lifetime are reported as cost/QALY gained or incremental cost effectiveness ratio (ICER). Thresholds for investments have to be defined. ICER analysis can lead to controversial results for different age groups (e.g., screening for trisomy 21) or when comparing different policies (e.g., fetal DNA blood group screening for targeted antenatal anti-D prophylaxis versus no or general prophylaxis) .
Meta-analyses and patient information leaflets use relative risk reductions (RRRs) but should also show absolute risk reductions because RRRs can wrongly suggest that benefits are large; although the absolute risk and improvement are very small, they remain a large percent of the original absolute risk . The number needed to treat (NNT) or prevent (NNP) characterizes the number of patients who need to receive clinical management to achieve target outcomes . A threshold is the maximum number of patients a clinician is willing to treat to prevent one target outcome, the NNTt or the NNPt. . The minimum event rate for treatment (MERT) justifies a treatment, calculated as MERT=1/(NNPt x RRR) . The minimum control event rate (CERmin) is defined as CERmin=TER+(DC/(QALYs gained x $50000)), where TER represents a treatment event rate. Graphs of QALYs versus the logs of NNPt or CERmin illustrate under- or overuse of resources .
In reality, the thresholds to prevent a disease will vary according to the co-morbidities and the expected intervention efficacy (RRR): patients with a history of pre-eclampsia (PE), a body mass index (BMI) > 30, or assisted reproductive technology (ART) have a NNPt below 250 for low-dose aspirin to prevent PE expecting RRRs of 10–50% ( Figure 1 ) . Similar graphs for other conditions would allow obstetricians to integrate risk factors in a patient’s history into more rational decision-making. QUALYs and ICERs should include the long-term health of the mother and child to favor early interventions .
Return on investment (ROI) is used by hospital managers who know the terms from portfolios: a high ROI implies that gains compare favorably to cost . Defining a “YEAR 0” eliminates the problem of estimating measures based on uncertain assumptions ( Table 1 ). ROI/potential gained life years can be defined, which tripled by introducing family planning to prevent stillbirth and maternal mortality in South Africa . Many calculations are based only on models and should be interpreted with caution. For details, the International Society for Pharmacoeconomics and Outcomes Research provides checklists and supports for decision-making.
| YEAR | Predicted outbreak patient days | Observed average patient days | Difference in outbreak patient days | Difference in outbreak costs (€) | Incremental rise infection prevention budget (€) | Difference infection prevention costs (€) | ROI |
|---|---|---|---|---|---|---|---|
| 2007 | 1872 | 1872 | – | – | – | – | – |
| 2008 | 2157 | 330 | 1826 | 958,912 | 134,049 | 782,341 | 5.84 |
| 2009 | 2455 | 1248 | 1207 | 633,520 | 195,515 | 409,912 | 2.10 |
| 2010 | 3154 | 5285 | −2131 | −1,118,736 | 138,130 | −1,207,257 | −8.74 |
| 2011 | 3147 | 1285 | 1862 | 977,749 | 191,843 | 742,549 | 3.87 |
| 2012 | 2763 | 1505 | 1258 | 660,660 | 115,491 | 515,873 | 4.47 |
| 2013 | 2799 | 2679 | 120 | 62,756 | 222,046 | −162,072 | −0.73 |
| 2014 | 2923 | 1211 | 1712 | 898,711 | 110,526 | 748,333 | 6.77 |
Improvement research integrates continuous data collection with the work itself. Professionals should define core principles and create scientific improvement methods . Tips on how to incorporate improvement research into daily work have been published . Should it not be part of every obstetric unit?
A brief review of economic analysis in the clinical setting
Although the nomenclature of economic analysis can seem remote from clinical practice, to ignore it would be a mistake. Deriving from Latin “surgere” (to rise), resource symbolizes inner strength. Sometimes, we are left to our own resources. After productivity studies in the Hawthorne Company, Mayo concluded that employees are far more motivated by relational factors than by monetary rewards or work environment . Developments in organizational behavior claimed legitimacy for Human Resource Management (HR). The Chartered Institute of Personnel & Development and societies for HR were founded. The expression HR can be abused, as by Stalin, who acknowledged its importance but applied brutality, secrecy, and ambiguity . In healthcare institutions, HR minimizes costs by acquiring appropriate staff and providing training and maintenance of competency. Engaged and fulfilled rather than abused healthcare workers and physicians help optimize the patient experience.
Cost-effectiveness analyses (CEAs) were used by farmers to measure productivity , and its use has become popular for many other applications. The CEA guide of the World Health Organization (WHO) stresses that CEA is only one input for the use of resources; interventions should also address inequalities . The ethical principle of justice supports the concept of equity, which is the absence of avoidable or remediable differences. Life losses are calculated as years of potential life lost, estimating the number of years a person would have lived without premature death. Cost-benefit analysis (CBA) assesses the economic value of beneficial outcomes against the cost of achieving them. CEA and CBA have obvious clinical applications. It is therefore of interest that the number of obstetric publications with the Mesh-terms CBA versus CEA is less than 10%.
The burden of disease measures mortality and disability-adjusted life years (DALYs) . Although societies are severely affected by maternal mortality, the correlation with DALYs is problematic . Economic assumptions by cost/DALY as used in low-income countries cannot be generalized because human resources (e.g., availability of obstetricians) play a role. For example, costs/DALY by providing Cesareans for obstructed labor ranged from $251 in Madagascar to $3,462 in Oman . With respect to unjustified maternal or neonatal death, the use of CEA sounds harsh because such outcomes are professionally unacceptable.
The concept of quality-adjusted life year (QALY), where one QALY equates to 1 year in perfect health, has been more often used in high-income countries, although its use for selective adjustment has been criticized . The health-related benefits accrued over a woman’s lifetime are reported as cost/QALY gained or incremental cost effectiveness ratio (ICER). Thresholds for investments have to be defined. ICER analysis can lead to controversial results for different age groups (e.g., screening for trisomy 21) or when comparing different policies (e.g., fetal DNA blood group screening for targeted antenatal anti-D prophylaxis versus no or general prophylaxis) .
Meta-analyses and patient information leaflets use relative risk reductions (RRRs) but should also show absolute risk reductions because RRRs can wrongly suggest that benefits are large; although the absolute risk and improvement are very small, they remain a large percent of the original absolute risk . The number needed to treat (NNT) or prevent (NNP) characterizes the number of patients who need to receive clinical management to achieve target outcomes . A threshold is the maximum number of patients a clinician is willing to treat to prevent one target outcome, the NNTt or the NNPt. . The minimum event rate for treatment (MERT) justifies a treatment, calculated as MERT=1/(NNPt x RRR) . The minimum control event rate (CERmin) is defined as CERmin=TER+(DC/(QALYs gained x $50000)), where TER represents a treatment event rate. Graphs of QALYs versus the logs of NNPt or CERmin illustrate under- or overuse of resources .
In reality, the thresholds to prevent a disease will vary according to the co-morbidities and the expected intervention efficacy (RRR): patients with a history of pre-eclampsia (PE), a body mass index (BMI) > 30, or assisted reproductive technology (ART) have a NNPt below 250 for low-dose aspirin to prevent PE expecting RRRs of 10–50% ( Figure 1 ) . Similar graphs for other conditions would allow obstetricians to integrate risk factors in a patient’s history into more rational decision-making. QUALYs and ICERs should include the long-term health of the mother and child to favor early interventions .
Return on investment (ROI) is used by hospital managers who know the terms from portfolios: a high ROI implies that gains compare favorably to cost . Defining a “YEAR 0” eliminates the problem of estimating measures based on uncertain assumptions ( Table 1 ). ROI/potential gained life years can be defined, which tripled by introducing family planning to prevent stillbirth and maternal mortality in South Africa . Many calculations are based only on models and should be interpreted with caution. For details, the International Society for Pharmacoeconomics and Outcomes Research provides checklists and supports for decision-making.
| YEAR | Predicted outbreak patient days | Observed average patient days | Difference in outbreak patient days | Difference in outbreak costs (€) | Incremental rise infection prevention budget (€) | Difference infection prevention costs (€) | ROI |
|---|---|---|---|---|---|---|---|
| 2007 | 1872 | 1872 | – | – | – | – | – |
| 2008 | 2157 | 330 | 1826 | 958,912 | 134,049 | 782,341 | 5.84 |
| 2009 | 2455 | 1248 | 1207 | 633,520 | 195,515 | 409,912 | 2.10 |
| 2010 | 3154 | 5285 | −2131 | −1,118,736 | 138,130 | −1,207,257 | −8.74 |
| 2011 | 3147 | 1285 | 1862 | 977,749 | 191,843 | 742,549 | 3.87 |
| 2012 | 2763 | 1505 | 1258 | 660,660 | 115,491 | 515,873 | 4.47 |
| 2013 | 2799 | 2679 | 120 | 62,756 | 222,046 | −162,072 | −0.73 |
| 2014 | 2923 | 1211 | 1712 | 898,711 | 110,526 | 748,333 | 6.77 |
Improvement research integrates continuous data collection with the work itself. Professionals should define core principles and create scientific improvement methods . Tips on how to incorporate improvement research into daily work have been published . Should it not be part of every obstetric unit?
Patient level
Truth telling was endorsed as a professional obligation as early as 1903 . Well-informed patients experience better quality of life . Shared decision-making can reduce participation in useless clinical cascades . The US Institute of Medicine and the US Center for Medicaid and Medicare Services named patient-centered care a fundamental aim in improving healthcare .
Interrupting vicious circles before pregnancy
Preventing unhealthy lifestyles is a clinical challenge. Food industries spend billions to contribute to a global obesity epidemic and thereby nudge children to unhealthy eating habits that can last a lifetime. The prevalence of impaired glucose tolerance, hypertension, and raised cholesterol in European children was 8.4%, 21.8%, and 22.1%, respectively . An obese child will incur elevated medical costs of approximately USD 19,000 compared to a child with normal weight; additional maternity costs for severely obese women were about UKS 350.75 . By 2020, the projected economic burden of obesity unrelated to pregnancy is estimated to rise by £1.9–2.0 billion/year in the United Kingdom (UK) or $48–66 billion/year in the US . Risks track from childhood into adulthood as pregnancy complications, cardiovascular disease (CVD), hypertensive disorders (HD), or metabolic syndrome . Fetuses of obese mothers already show signs of cardiac lesions within the first trimester . “Obesogens” program prenatal vascular insults , cause early postnatal death in animals and humans , and cause vicious circles of noncommunicable diseases (NCDs) across generations.
Protection could be achieved by restricting the marketing of energy-dense, nutrient-poor foods and beverages or targeting children and parents for healthy eating habits. Children were asked to help develop joyful health programs . Early diet and physical activity interventions are cost-effective and prevented childhood obesity in randomized controlled trials (RCTs) . Media and apps are sources of information for adolescents; however, these are produced to be sold and are rarely neutral. This may be changed if clinical scientists would leave their “ivory towers” and engage the public, e.g., by utilizing social media. The ethical imperative for clinicians is to share information and for patients to be equal participants . The partnership should already frame preconceptional lifestyles, although there are benefits when obese pregnant women are instructed .
Preventing unintended pregnancies diminishes maternal mortality rates in low-income countries. In Nigeria, this public health measure reduced up to one in five abortion-related deaths with ICERs of approximately USD $500/YLS, which is below the per capita gross domestic product (GDP) . Among the OECD countries, the US and Hungary had the highest adolescent pregnancy rates . Early sexual activity in the Netherlands equaled that of the US, but unintended pregnancy rates were 7% versus 50%. Pragmatic contraceptive support in the Netherlands differs from the mixed message sent in the US to adolescents in an ambivalent society that suggests that premarital sex is romantic but immoral. For these pregnancies and infants, the US spends $11 billion in annual public insurance costs . The UK ranks fourth worst in Europe . Every £1 spent on contraception saves the public £11. A 10% cut for contraception could cost an extra £8.65 billion because of unwanted pregnancies or sexually transmitted infections . More worrying is the likelihood of emotional, medical, and educational harm that represents vicious circles of social inequity, thus reducing life chances for mothers and children who again have low educational achievements and early pregnancy rates. Contraceptive-promoting interventions lowered teenage pregnancies with a blood pressure (RR) of 0.66 and a 95% confidence interval (CI) of 0.50-0.87 . Emphasizing condom use reduced “no prevention” with an odds ratio (OR) of 0.61 (0.45-0.85) . A review concluded that subsequent births were reduced with home-based interventions, but more rigorous programs need to be started as soon as possible after the first unintended delivery . Psychosocial interventions in the UK lowered teenage pregnancy rates . A systematic review identified >200 apps related to contraception, but their effectiveness was not evaluated . Women overestimate the risks of long-acting reversible contraception , but imperfect adherence of teens should lead to easy access to long-acting contraception .
Interrupting vicious circles during pregnancy
Pregnant women have to make heuristic decisions. Neuroscientists distinguished between the small world where probabilities are so clear that patients can optimize decisions and the large world of uncertainty, where information is incomplete. Surprises are preprogrammed when physicians do not inform about equipoise. Functional magnetic resonance imaging showed that cerebral processes differ under both circumstances of decision-making . Libertarian paternalists argue that authorities need to steer healthcare decisions . Gynecologists may not instruct “irrational” pregnant women, although the same women could decide rationally when appropriately informed. Companies steer media reports: “Due to cell-free (cf)DNA, no sick babies will be born” was a headline in a German newspaper. However, obstetricians should inform women who wish a comprehensive assessment to choose for karyotyping and microarray analysis by invasive testing since loss rates are smaller (<0.1%) than speculated . The first population-based nonindustry-funded trial randomized 2111 French women with a risk for trisomy 21 of 1/250 to compare cfDNA and invasive testing. There was no difference in fetal loss rate (1.3% vs. 1.24%), but 13 additional abnormalities were diagnosed in the invasive group . The NNT for cfDNA to detect (not treat) one case with trisomy 21 was 1266. Such studies should have been performed before the commercial introduction of cfDNA testing. Regrettably, regulations do not require the comparison of new and traditional practices, and physicians are not critical enough. Vicious circles of women’s avoidable ignorance could be minimized when parents were referred to neutral information before stress or emergency situations limit rational decision-making. This holds true for other screening or treatment policies, such as threatened preterm birth, PE, or gestational diabetes (GDM). Fact boxes as proposed for cancer screening would be one option to inform patients neutrally ( Table 2 ) .
| 1000 women without screening | 1000 women with screening | |
|---|---|---|
| Benefits | ||
| How many women died from breast cancer? | 5 | 4 |
| How many women died from all types of cancer? | 21 | 21 |
| How many women died from any cause? | 84 | 84 |
| Harms | ||
| How many women without cancer experienced false alarms or biopsies? | – | 50–200 |
| How many women with non-progressive cancer had unnecessary partial or complete removal? | – | 2–10 |
Interrupting vicious circles after pregnancy
Diseases during pregnancy can have lifelong health implications, predisposing the fetus to low birth weight and later health risks (Barker hypothesis) . Pregnancy complications can indicate maternal or even grandparent’s risks for NCDs (reverse Barker hypothesis) . Recently, we reviewed the long-term impact of risk profiles for both the mother and child to show the complex interplay of genetics and epigenetics . Irritations provoked by unprofessional risk information have to be replaced with education and mutual care decision-making, which can increase preventive healthcare .
Breastfeeding support is recommended for 6 months, followed by 1 year with complementary foods . However, global sales of breast milk substitutes reached $40 billion in 2013. Marketing targeted directly to “consumers” is widespread even in countries that have adopted the WHO policy to restrict such activities. Breastfeeding reduces risks and increases benefits to the mother and child: in the US, short breastfeeding rates result in 4981 yearly excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction and incur $17.4 billion resulting from premature death and $733.7 million in direct and $126.1 million in indirect morbidity costs . In children, breastfeeding reduces infections, sudden infant death, leukemia, and asthma and ameliorates cardiovascular remodeling induced by fetal growth restriction . In mothers, breastfeeding mobilizes fat; reduces rates of heart disease, overactive stress responses, breast or ovarian cancer; and protects women with GDM from type 2 diabetes .
Consultation and surveillance after pregnancy similarly decreases costs and risks: the American diabetes prevention trial supports a balanced diet and an active lifestyle after GDM . In the UK, a mean ICER of £7355 was evaluated for weight management programs in obese mothers . A 10% increase in treated early HD after PE would prevent 14,000 deaths . A new Dutch guideline proposes to optimize the modifiable risk factors of PE for CVD . The US Centers for Disease Control recommends interpregnancy care . Pregnancy data should be available life-long: in Canada, women with a history of PE showed a four-fold risk of death during cardiac interventions . The American Heart Association includes GDM and high diastolic pressure in their assessment . Text reminders to search controls is a creative concept . A prospective US cohort trial is ongoing to establish more details . In addition, children from mothers with PE are three times more likely to develop targetable hypertension as young adults .
The UN General Secretary Ban Ki-moon declared during the first NCD-conference of WHO and UNO, “We strive for an international commitment that puts NCDs high on the development agenda” . Down to earth, this declaration should be translated into family programs to interrupt vicious circles indicated by pregnancy-related syndromes. Obstetricians should change communication from questionable persuasion to something straightforward and not neglect future health aspects of their patients . Could coproduction or person-centered care be new watchwords?
Physician level
The wide variety of tests, procedures, and medications that obstetricians use supports the hypothesis that obstetric care is insufficiently based on scientific standards but on clinicians’ readiness to follow fiduciary professionalism or (false) incentives. This is reflected by a disparity of priorities within an institution, a country, or different systems. To rely on trusted professionalism disconnected from evidence-based reasoning seems naïve. Highlighting differences among physicians can threaten insecure specialists. Vices such as bias, primacy of self-interest, hard-heartedness, and corruption undermine a professional culture between patients and physicians or chairs and faculty colleagues . In most settings, physicians are reimbursed for providing care units, regardless of benefits for patients or society .
Deficits in obstetric care in high-income countries are more because of a lack of knowledge than a lack of money . The overflow of scientific publications has led to less trustworthy summaries in non-peer-reviewed journals or Internet pages. Playing and listening to music or reading critics is not the same. A Statistical Literacy Questionnaire for Obstetrics and Gynecology (OBGYN) was distributed to US gynecologists, who did poorly on questions about facts, statistics, and relationships, with 0%, 7%, and 36% answering correctly, respectively; 49% could determine a positive predictive value . If basic knowledge is lacking, scientific studies can hardly be interpreted, criticized, or implemented.
Low professional skills combined with fears of professional litigation result in rising costs, rising insurance premiums, and subsequent coverage restrictions. Employed obstetricians fulfill hospital-owed obligations if patients are not entitled to choose a physician or care is complex . Worries about lawsuits have caused an increase in Cesarean delivery rates . After adverse events, obstetricians cumulatively increase Cesareans by 8% and thus have fewer malpractice incidents . However, the Cesarean epidemic has its price: the WHO estimated that worldwide 6.2 million Cesareans are unnecessary, but 3.2 million were needed, resulting in yearly costs of global “excess versus needed” Cesareans of $2.32 billion versus $432 million . Even worse are the fetal and maternal risks in subsequent pregnancies . Regional high rates of Cesareans cause increased risks of maternal mortality .
There is a deep gap between evidence and its clinical application, expressed as a steady drop from awareness, acceptance, applicability (diagnosis/treatment), availability and ability (competence), recall or agreement (patient’s opinion or interpretation), and adherence. In 50% of hospitals in Western countries with private health care such as the US or Germany, it took at least 17 years until accepted medical innovations were introduced .
By using Medline, the term “CEA” was related with core procedures and outcomes. This article can only provide an overview of the increasing publications and trials ( Table 3 ). Ethical antidotes to control waste are to keep economic self-interest in its secondary place, to create cultures that reward humility in accepting correction and integrity, compassion, self-effacement, and self-sacrifice . Ethical skills reduce malpractice litigation and discourage the arrogance of idiosyncratic judgments .
| CEA/general obstetric terms | All | 2011–16 | CEA/screening and diagnosis | All | 2011–16 | CEA/interventions | All | 2011–16 |
|---|---|---|---|---|---|---|---|---|
| Delivery | 6830 | 2079 | Routine preg-nancy screening | 645 | 175 | General pregnancy treatment | 2509 | 582 |
| Birth | 1604 | 515 | Abdominal Ultrasound | 210 | 59 | Contraception | 519 | 103 |
| Obstetrics | 1569 | 561 | Amniocentesis | 117 | 14 | Cesarean | 261 | 62 |
| Abortion | 386 | 69 | Screening for GDM | 70 | 35 | Hospitalization | 205 | 35 |
| Perinatal Medicine | 313 | 86 | Transvaginal Ultrasound | 60 | 26 | Tocolytics | 185 | 34 |
| Maternal Mortality | 325 | 122 | Screening for toxoplasmosis | 44 | 19 | Patient information | 123 | 46 |
| Preterm birth | 282 | 92 | Screening for preterm birth | 43 | 18 | Antibiotics during pregnancy | 112 | 14 |
| Perinatal Mortality | 178 | 40 | Screening for cytomegaly | 34 | 14 | Induction of labor | 98 | 24 |
| Breastfeeding | 176 | 59 | Chorionic villous sampling | 32 | 15 | Lifestyle interventions during pregnancy | 40 | 18 |
| GDM | 117 | 49 | Screening for pre-eclampsia | 32 | 15 | Corticosteroids for lung maturity | 25 | 4 |
| Maternal-fetal Medicine | 146 | 51 | Screening for thallasemia | 32 | 12 | Vaginal Progesterone to prevent SPB | 20 | 12 |
| Pre-eclampsia | 73 | 29 | Screening for spina bifida | 20 | 1 | Aspirin | 13 | 4 |
| Obesity during pregnancy | 45 | 25 | Screening for developmental hip dysplasia | 14 | 3 | Interventions for Obesity | 10 | 7 |
| Twin pregnancy | 41 | 10 | Non-invasive genetic testing | 12 | 9 | Cerclage | 9 | 3 |
| Education | Fibronectin | 9 | 5 | OHPC to prevent SPB | 8 | 3 | ||
| Teaching obstetrics | 166 | 71 | Screening for FHD | 9 | 2 | Antihypertensive drugs | 9 | 1 |
| Education of obstetrics | 130 | 55 | Non-invasive fetal RhD genotyping | 8 | 6 | Metformin | 7 | 4 |
| Postgraduate education | 27 | 19 | Cell-free D N A for trisomy 21 | 6 | 6 | Cervical Pessary | 5 | 1 |
| Perinatal Audits | 14 | 5 | Screening for vasa previa | 1 | – | Interpregnancy care | 0 | 0 |
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