John J. Frey

Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center

PURPOSE Recent national guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing vaginal births after cesarean (VBACs) and decreasing the high US cesarean birth rate and its consequences (2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guideline). A birthing center serving Amish women in Southwestern Wisconsin offered an opportunity to look at the effects of local culture and practices that support vaginal birth and TOLAC. This study describes childbirth and perinatal outcomes during a 17-year period in LaFarge, Wisconsin. METHODS We undertook a retrospective analysis of the records of all women admitted to the birth center in labor. Main outcome measures include rates of cesarean deliveries, TOLAC and VBAC deliveries, and perinatal outcomes for 927 deliveries between 1993 and 2010. RESULT S The cesarean rate was 4% (35 of 927), the TOLAC rate was 100%, and the VBAC rate was 95% (88 of 92). There were no cases of uterine rupture and no maternal deaths. The neonatal death rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000) and the United States (4.5 of 1,000). CONCLUSIONS Both the culture of the population served and a number of factors relating to the management of labor at the birthing center have affected the rates of cesarean delivery and TOLAC. The results of the LaFarge Amish study support a low-technology approach to delivery where good outcomes are achieved with low cesarean and high VBAC rates.

Patient Relationships and the Personal Physician in Tomorrow's Health System: A Perspective from the Keystone IV Conference

A group of senior leaders from the early generation of academic family medicine reflect on the meaning of being a personal physician, based on their own clinical experiences and as teachers of residents and students in academic health centers. Recognizing that changes in clinical care and education at national and local systems levels have added extraordinary demands to the role of the personal physician, the senior group offers examples of how the discipline might go forward in changing times. Differently organized care such as the Family Health Team model in Ontario, Canada; value-based payment for populations in large health systems; and federal changes in reimbursement for populations can have positive effects on physician satisfaction. These changes and examples of changes in medical student and residency education also have the potential to positively affect the primary care workforce. The authors conclude that, without substantive educational and health system reform, the ability to truly serve as a personal physician and adhere to the values of continuity, responsibility, and accountability will continue to be threatened.

Is Obamacare working

The answer, as one might imagine, depends completely on whom you ask. The recent, end of March deadline had most members of the Obama administration very happy, showing over 8 million people signed for insurance through state and federal exchanges, which exceeded their goals.1 Overall, 31 states exceeded their targets for enrolment, including a number of heavily Republican states in the South.2 So the answer from the administration would be ‘yes’. The Republicans would say, of course, ‘no’, because that is what they say about anything that might extend financial support for people on a low-income, especially anything proposed by President Obama. The Republican House has voted 54 times now to repeal or alter the Affordable Care Act (ACA). It gives them something to do while they are not passing any legislation of importance on, let’s say, climate change or immigration. States could either design the exchange process themselves or punt it to the federal exchange, which has had well-publicised start-up problems and website crashes. The states that chose to do it themselves were often surprising. Kentucky is a poor state whose economy relies on tobacco and coal (not the best products on which to build a future). Yet Kentucky, led by a practically minded Democratic governor and despite having two of the more reactionary senators in Congress, used federal dollars to help dramatically increase the number of people on Medicaid and begin to enrol people in private programmes. Georgia and Florida were two other states with large enrolments through the federal exchange. Both states are seeing a large demographic shift with increases in African-American and Latino populations that are changing the voting profile to potentially be more Democratic. The governor of Florida, a former champion of industry in the country’s largest for-profit healthcare system, which paid

Unresolved Intergenerational Issues

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Call for stories of on-the-ground innovations in primary health care

The Keystone III Conference was held October 4–8, 2000, as a structured conversation about the current state and future of family medicine.[1][1],[2][2] Inspired by prior conversations organized by family medicine pioneer G. Gayle Stephens, MD, in 1984 and 1988,[3][3] Keystone III stimulated the

In This Issue: Generalist Care Around the World

This is a revolutionary time in primary health care. Groundbreaking advances are being implemented in a variety of settings. Although most of the revolution is invisible through the usual lenses of measurement, research, and publication, important advances are taking place. Some advances address

In This Issue: Back to Basics: Talking, Listening, and Low-Tech Primary Care

One of the important lessons we have learned over the years is that understanding the context of care is essential for understanding the relevance of studies.1 No context could be more important than the health system in the country in which the research takes place. Since this issue of the Annals has articles from 7 different countries, one challenge is how these studies might be generalizable. Despite the differences in health systems, it is remarkable to see how the process of care in generalist practice continues to have as much in common as it has differences.

In This Issue: Relationships Count for Patients and Doctors Alike

Communication plays a central role in 3 manuscripts in this issue: communication with patients about health risk, communications with family and patients about end-of life-care, and communication with patients with intellectual disabilities. As one of my teachers once reminded me, we may send a

All for one, but more for me

The enthusiasm for and adoption of certifying criteria for medical homes, despite little research into the effects of these criteria on both patients and clinicians, raises the concern that this codification of primary care could have unanticipated, negative consequences. A previous article in the

Playing the poor in the US

A learned friend of mine told me that health care is the next US economic bubble. He said that when the housing and dot-com bubbles burst, the first hit were those with vulnerable mortgages and speculative stocks. The collapse then rumbled through the rest of society and the world. When the healthcare bubble bursts, everyone in the country will be hit and it will not be pretty. For the past decade, polls showed that the American public feels health care needs a major overhaul. Everyone feels vulnerable. No one understands the current system. For the past 5 years, even insured Americans found their personal share of costs increasing for everything from doctor visits to drugs to emergency care. Those who have lost their health insurance are unable to purchase comparable individual or family insurance of any type.1 In a bit of disingenuous political solidarity, the CEO of the trade association that represents US health plans, sometimes referred to as the Evil Empire, recently admitted that, due to a pre-existing condition, even she might not be able to afford individual insurance in …