Cesarean Sections as a Last Resort

Cesarean Sections as a Last Resort

Delivery

The most common surgery in the United States is the cesarean section (C-section), so named because Julius Cesar is said to have been born this way. It may also be the nation’s most overperformed operation, say many experts. Approximately 1 in 4 babies in the United States are delivered by cesarean birth; in Canada the rate is about 1 in 5, and in Great Britain it is 1 in 10. And while the rate of C-sections has leveled off in the United States since 1989, the incidence remains almost five times higher than it was in 1969.

The reason for the high volume of cesarreans may be as much legal as medical. The American College of Obstetricians and Gynecologists (ACOG) has suggested that physicians’ fears of being sued for their handling of difficult deliveries may be much to blame for the medical profession’s propensity to elect C-sections over vaginal deliveries in many cases.

The widespread use of electronic fetal monitoring, a technique that makes it easier for the doctor to detect potential problems in the delivery early, only adds to this jumpiness.

According to ACOG, a self-fulfilling prophecy may also be at work to some extent: once a woman has had one C-section, obstetricians have often fallen into a habit of assuming that a cesarean would be required should the woman ever give birth again.

Other critics have argued that the medical establishment’s fondness for cesareans is inspired by a more cynical factor: insurance reimbursement rules that provide substantially higher fees for doctors and hospitals performing C-sections than for those delivering without the need for surgery. These critics point to studies showing that cesareans are more likely to be performed in profit-making hospitals and on women with private health insurance.

Cesarean Section. Photo by Elena

Whatever the reasons, most experts agree that in the absence of medical complications, women should be encouraged to attempt vaginal labor rather than undergo a cesarean. Successful vaginal delivery significantly reduces the risk of complications, both during and after the surgery, as well as cuts down the stay required in the hospital from nearly five days to about half of that, with all the financial savings that that entails.

Even women who have had a prior C-section can deliver vaginally the next time around an 60 to 80 percent of cases, says ACOG. Vaginal deliveries are strongly discouraged, however, if a woman’s previous cesarean involved either a classical uterine incision, in which the cut was made in an up-and-down direction in the upper part of the uterus, or if warning signs such as an abrupt change in the fetal heart rate appear. Nevertheless, in most cases “the relative safety of vaginal delivery after cesarean birth is compelling,” says ACOG, and “women should be counseled and encouraged to undertake a trial of labor.”

Risk of miscarrying: Miscarriage is nature’s way of ending a pregnancy that is not proceeding normally. About a fifth of all pregnancies end this way, mostly during the first trimester, but in some cases as late as the first half of a pregnancy. Heavy bleeding from the uterine lining is the most common warning sign. Cramping pain, usually more severe than menstrual cramps, can also be a symptom

The Outlook for Prescriptions

The Outlook for Prescriptions

Mail-order suppliers are one of the few ways to fight rising costs

Political power, declared Chairman Mao, comes from the barrel of a gun. Political clout has even been known to keep prescription drug prices down temporarily. But as the Clinton administration discovered when it tried to jawbone down drug prices, moral suasion only works so long as people fear your political might.

According to the Bureau of Labor Statistics, inflation rises and drug prices increase sometimes over three times a year's inflation rate. That upward spiral slow sometimes, as the authorities lead an all-out drive to overhaul the health care system and to curtail costs. Politics is a factor, say economists who track drug prices for the Bureau of Labor Statistics. Feeling the heat, pharmaceutical companies made a pledge to restrain prices t overall inflation. As a result, wholesale drug prices rise more slowly, according to a Pharmaceutical Manufacturers Association spokesman. When the administration has to abandon its health care reform plan in the face of overwhelming political opposition, medical prices jump in a single month.

Through drug prices rises have moderated some since then, most experts believe the increases will continue to outstrip inflation. “It's expensive to do research on new drugs – someone has to pay. There's no free lunch.

Managed-care companies have had some effect on moderating price increases because of the bargaining strength these providers have with the drug makers who supply them. But even managed-care plans are having difficulty keeping drug prices affordable. According to the trade publication, Drug Topics, the cost of ingredients in the average drug prescription for HMO participants skyrocketed in the 21th century.

Outlook for prescriptions. Photo be Elena

One restraining force on price hikes today are mail-order drug distributors. Beginning after World War II, the federal government began a program that allowed veterans to buy prescription drugs through the mail. Now the largest distributor of mail-order-order drugs, the Department of Veterans Affairs fills dozen of millions of prescriptions a year. After the DVA launched its mail-order service, the American Association of Retired Persons followed suit. Today AARP fills some 10 million prescriptions annually. Anyone can use the service. It's not just for AARP members.

Many corporations, unions, governmental entities, and managed-care organizations also have mail-order plans. Called pharmacy benefit managers (PBMs), these mail-order services offer prescription drugs for chronic illnesses such as diabetes, though not for acute illnesses such as infections. Depending on the case, PBMs can cut drug costs by a third or more, according to some estimates.

The three largest PBMs are PCS Health Care Systems, Diversified Pharmaceutical Services, and Medco Containment Services, and their business is booming. According to the American Managed Care Pharmacy Association, mail-order drug sales have grown from. Medco says that it has dozens of millions of continuing customers, with many of them in formulatory-based programs, which means that generic brands are used.

Their customers' needs are handled through National Rx, a mail-order pharmacy network with many centers, and Medco's retail pharmacy chain, which includes over 46,000 pharmacies nationwide.

Some PBMs have disease management programs, which help cut costs further by educating patients on the most effective treatments for their conditions. Medco has a database, for instance, that identifies high-risk or high-cost patients.

Someone with asthma would be considered a high-risk patient, for instance, because asthma sufferers often fail to use their inhalers properly, leading to needless medical problems and needless expense. In a disease management program, a pharmacist would provide asthma patients with instruction in the way to use inhaler to forestall asthma attacks.

If doesn't help, the pharmacist can also consult with the patient's doctor on whether a different prescription might be in order. The result: The patient receives better treatment and it costs less to boot.

Path Across the Nation

Paths Across the Nation

Some are no wider than a fat guy, but all are of scenic or historic value

While they many not have hiked it top to bottom, most Americans have heard of the Appalachian Trail. Many are unaware, though, that the Appalachian belongs to a much larger system of trails. In 1968, Congress passed the National Trails Assistance Act to establish a national trail system. The trails fall into two categories: national scenic trails, which are protected scenic corridors for outdoor recreation, and national historic trails, which recognize prominent pas routes of exploration, migration, and military action and may consist of no more than a series of roadside markers. The entire system includes about a two dozen trails and covers most of the country.

National Scenic Trails

Benton Mackay, the man who created the Appalachian Trail, thought it shpuld be no wider than the space required by the average fat man. The majority of the trails are open to hikers only, although some allow mountain bikes and horses. Many are works in progress and have significant sections closed to the public. Call ahead to inquire about available sections, allowable modes of transportation, and camping permits.

Appalachian National Scenic Trail: Appalachian Trail Conference. Length: 2,144 miles. The first interstate recreational trail, the Appalachian was conceived in 1921 by Benton McKay as a national preserve parallel to the East Coast. Beginning in Georgia and ending in Maine, the trail hugs the crest of the Appalachian Mountains and is open only to hikers. There are shelters every 6 to 12 miles, making it possible to hike the entire span without leaving the trail. Approximately 175 people hike the entire length of the trail every year, while millions of other hikers find inspiration and adventure on shorter segments.

The nature blossoms. Photo by Elena.

Continental Divide National Scenic Trail: Length : 3,100 miles. The Continental Divide Trail provides spectacular backcountry travel through the Rocky Mountains from Mexico to Canada. It is the most rugged of the long-distance trails. About 99 percent of the entire 3,100 miles is finished in some form, and the Forest Service hopes to complet the rest very soon. So it os possible for the more adventurous to hike from border to border . The longest contonuous finished stretch reaces 795 miles from Canada through Montana and Idaho to Yellowstone National Park, and there is another solid 400-mile stretch through Colorado. The trail is open to hikers, pack and saddle animals, and, in some places, off-road motorized vehicles.

Florida National Scenic Trail: Length: 1,300 miles. The Florida Trail extends from Big Cypress National Preserve in South Florida to just west of Pensacola in the northern part of the Florida Panhandle. Formed in 1964, the trail will eventually extend through Florida's three national forests to Gulf Islands National Seashore in the western panhandle. The trail passes through America's only subtropical landscape, making it especially popular with winter hikers and campers. Side-loop trails connect to nearby historic sites and other points of interest. At present, Forest Service officials estimate that about 600 miles of the trails are in place and open to public use.

Ice Age National Scenic Trail: Length: 1,000 miles. At the end of the Ice Age, some 10,000 years ago, glaciers retreated from North America and left at their southern edge a chain of moraine hills made of rocks and gravel that the glaciers had accumulated along their journey. In Wisconsin, this band of hills zigzags across the state for 1,000 miles from Lake Michigan to the St.Croix River. Almost half the trail is open to the public, and certain sections are sometimes even used for marathons, ski races, and super long-distance running across the trail's rough terrain.

Natchez Trace National Scenic Trail: Length: 110 miles. The trail lies within the boundaries of the as yet uncompleted Natchez Trace Parkway, which extends 450 miles from Natchez, Miss, to Nashevlle, Tenn. The parkway will commemoratte the historic Natchez Trace, an ancient path that began as a series of animal tracks and Native American trails. It was later used by early explorers, ”Kaintuck” boatmen, post riders, and military men, including Andrew Jackson after his victory at the Battle of New Orleans. Segments near Nashville (26 miles), Jackson (20 miles), and Rocky Springs, which is near Natchez (15 miles) have been completed, there also are about 20 shorter leg-stretcher trails throughout. The Park Service connected the entire 450 miles.

North Country National Scenic Trail:  Length: 3,200 miles. Conceived in the mid-1960s, the North Country Trail links the Adirondack Mountains with the Missouri River in North Dakota. The trail journeys through the grandeur of the Adirondacks, Pennsylvania's hardwood forest, the canals and rolling farmland of Ohio, the Great Lakes shorelines of Michigan, the glacier-carved lakes and streams of northern Wisconsin and Minnesota, and the vast plains of North Dakota – not to mention nine national forests and two national parks. Park officials say that the trail is now completed for hiking.

Pacific Crest National Scenic Trail: Length: 2,638 miles. Running along the spectacular shoulders of the Cascade and Sierra Nevada mountain ranges from Canada to Mexico, the Pacific Crest Trail is the West Coast counterpart to the Appalachian National Trails. It passes through 25 national forests and seven national parks.

Potomac Heritage National Scenic Trail: Length: 700 miles. The trail commemorates the unique mix of history and recreation along the Potomac River. Although it was established only in 1983, park officials say that everything is place: the 18-mile Mount Vernon Trail in Virginia, the 70-mile Laurel Highlands Trail in Pennsylvania, and the 184-mile towpath of the Chesapeake and Ohio Canal. The last 20 or so miles of the trail along the Chesapeake and Ohio provide a wonderful bicycle ride that ends in the heart of Washington, D.C.

A little bird. Photo by Elena.

Mastering the College Aid Game

Mastering the College Aid Game

An insider's guide to maxing out financial aid

Most people who apply for financial aid for school have only a hazy idea of how colleges make their decisions. But there are some important facts everyone should know before they even sit down to fill out the forms. Campus Consultants Inc., a firm that guides parents through the financial aid process, has these tips on how to qualify for the most financial aid possible.

Understand the angles: The theory is, the money goes where it's most needed. But people who better understand the system and how it works are going to get the most money. Few families understand how the aid process works. Most people are just gambling. Anyone can benefit, you just have to understand it. 

Don't rule out any school as being too expensive: Private schools are more flexible, and may be able to offer more financial aid since they are not as regulated as state schools. If a family can afford $15,000 and it's looking at a a $50,000 school, it might be eligible for $35,000 in financial aid.

Think local: If you really need the money, the worst thing you can do is go to a state school outside of the state in which you live. It's not popular and it's not good politically to give lots of aid to a student who is from out of state. The student isn't able to qualify for state aid. Instead, look at the state school in your state, or a private college in your state or out of state.

College Aid Game is really hard to understand. Photo by Elena.

Know the timeline: The family income that the institutions will look at starts in January of the child's junior year in high school and ends in December of the child's senior year in high school. During that time, parents should be wary of selling stock, withdrawing from pensions prematurely, or withdrawing from IRAs prematurely.

Put assets in the parent's name: In aid formulas, the student's solvency is weighed more heavily than the parents'. If you want to hope for financial aid, put the money in the parent's name, not in the child's name.

In divorce situations, assume the custodial parent has the bonus. The parent who had custody of the child for the previous 12 months before is the parent whose income will be scrutinized. In other words, the parent that the child lived with when the child was a senior in high school is the custodial parent. The custodial should fill out the financial aid forms. A handful of schools will look at both parents, but the majority don't.

Don't relay on the school's financial aid administrator. Financial aid administrators work for the school. They are going to put the school ahead of the family. Ask them what to do, how to save money, and they won't answer. They'll tell you the rules, but they put the needs of the school first.

Save regularly: Above all, parents should set aside as much money as they can on a regular basis. They should get into the habit of saving regularly. Parents shouldn't be intimidated by statistics quoting the astronomical cost of tuition. They should just save as much as they can, as regularly as they can.

The Dangerous Hand

The Dangerous Hand

By James Lincoln Warren. Excerpt

The next morning Treviscoe sat in his usual corner at Lloyd’s reading the Public Advertiser, there occasionally being some topic of interest to him in that well-circulated periodical, when Pofret staggered into the coffee-house.

Pomfret might not still have been drunk from the night’s revels, but neither had he recovered from what must have been an epic debauch. His eyes were red, his unshaven face was as rough as a cat’s tongue, and his attire was so carelessly arranged he might have posed for Hogarth’s series on the Rake’s Progress a generation earlier.

He searched the smoky room with bleary eyes and made straight for Treviscoe’s table. On cue, he sat next to Treviscoe with the full force of gravity, once again shaking the floor with a loud thump that startled the patrons.

He stared at Treviscoe with what might have been hostility.

“Coffee, for God’s sake,” he croaked to a passing waiter.

“Shame!” scolded an insurance man at the next table before turning his back on the spectacle of Pomfret in favour of his pipe.

Treviscoe put the newspaper on his lap.

“You appear to have survived some major trial since las we spoke,” he said, his voice sympathetic but his eyes not without a hint of amusement.

“Survived? Have I survived? I was not till this moment at all sure, that I had survived.”

“I see you before me whole, but not unscathed.”

“Not, not unscathed, by God.”

The insurance man at the next table turned to scowl ferociously but said nothing.

The Dangerous Hand. Photo by Elena

“Old Langlade’s a Huguenot, you know,” said Treviscoe, referring to the disapproving man. “I expect he thinks you’ve been drinking all night.”

“Not all night, sir. Not until… hold. Yesterday I sought your aid, and you refused me.”

“No, sir: yesterday you sought my services without benefit of compensation and were refused,” replied Treviscoe.

“Have you no pity?”

“Pity? Pity? For a man who should be wiser, and yet knowingly allows himself to be fleeced? Are you in earnest, sir?”

“Then you are resolved not to help me?”

“I’ve never been resolved against you, Mr. Pomfret. I will gladly help you o the appropriate terms, videlicet, ten per cent, of the amount I save you. These have always been my conditions, as is well know to you.”

“Ten per cent! Ten per cent, why, that comes to over fifty pounds!”

“Yesterday it would have been a mere fifteen. Tell me how you have lost even more.”

“Will you help me?”

“Do you agree to my terms?”

“You are a hard man,” Pemfret said dolefully, “but I agree to them, through under protest.”

Trevescoe covered his face with his hand as if suppressing an eructation; in fact he was hiding a smile. It was small wonder that jolly old Pomfret was a sharp’s target, given how much he hated to part with the stuff: he was as thrifty as a Scot. It must make stealing his money  delicious. Getting control of himself, he looked up into Pomfret’s ravaged eyes. “Now tell me all.”

Published in September 2000, Alfred Hitchcock’s Mystery magazine