Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare.

Medical tourism, a term that also can be used to describe medical outsourcing, is characterized by travel away from one's home region to procure treatment in another. It may take one of two forms: obligatory or elective. The former occurs when necessary treatments are unavailable or illegal in the place of origin. The latter includes elective and medically indicated procedures that, although available at the place of origin, may be delivered more quickly or in a more cost-effective manner in another location. Reproductive outsourcing is a special form of medical tourism that has quickly become an important area of present-day medicine because the changes of the last four decades have left all but the most advanced fertility centers breathless as they try to adjust their treatment protocols in effective and ethical manners. Legal and policy limitations have created a global environment where, in a rising number of instances, individuals and couples must travel elsewhere to procure fertility procedures that are unavailable back home. With low cost airfares to and from America, a growing number of "medical cartographers" have set out to map which places are the "best" (in terms of cost, effectiveness and timeliness), for what procedures, and for whom. On the other hand, physicians, legal experts and policy makers have only begun to shape how government and health care agencies should formally guide or regulate medical tourism. In doing so, a number of factors may challenge the limits of ethics, policy and legality in this most important trend in modern medicine.

A critical assessment of generic substitution for the obstetrician-gynecologist.

In the past decade, generic drugs have increased in market share severalfold. There are drugs used in obstetrics/gynecology that are of concern with regard to generic substitution, because they are believed to be well tested and essentially not dangerous. The present review is mainly of the use of generics in oral contraception and assisted reproduction. It seeks to answer the question, whether cost advantages, great or slight, offered by the generics are well worth the attendant need for increased vigilance by clinicians and, possibly, taking care of increased side effects or even mishaps resulting from lack of effectiveness (or excessive "effectiveness"). The discussion is based on the concepts of bioavailability and therapeutic equivalence.

Generics: what's in a name?

Historically, the most common intervention performed by physicians has been the writing of a prescription. Often the prescription was a combination of active agents and an inactive base. This art is no longer practiced in the United States. Currently, most prescriptions are written for specific "drugs." As the prescription is being written, the physician must decide to administer a brand-name or a generic equivalent. Generics are a class of medications prescribed for reasons of economy, and the physician and the patient expect that the therapeutic effect will be exactly the same as for the brand-name. Bioequivalence of specific agents can be assessed using the FDA's Orange Book. In addition to bioequivalence, many other scientific, ethical, and economic issues should be considered before a decision is made. Prescribing vigilance is necessary, because in many instances available information is often controlling or insufficient to support rational decisions. Brand-names, rather than generics, should be selected when the therapeutic index is narrow or if the likelihood of generic switching is high. The paper will discuss all aspects of the subject.

Perception of risk, choice of maternity site, and socio economic level of twin mothers.

The objective of this study was to determine if access to high level health facility (level 3 perinatal center) is related to socio-economic level of the mother and to her perception of risk for a twin birth. A retrospective questionnaire was administrated to the mothers of twins during the first post parum days in each of the 27 maternity sites within a defined geographical district near Paris (Hauts de Seine). The survey instrument was designed to precisely characterize the socioeconomic status of the parents, to measure the perceived risk for the twins expressed by the mother, to measure the relationship between the choice of a maternity site (level 1, 2 or 3) by socioeconomic level, and to measure the fetal and neonatal death rates by socioeconomic status. The opinion of mothers of twins about specific risk for her and for her children is very different by socioeconomic levels, as is the choice of level 3. This is discussed with the rates of fetal and neonatal death rates by socioeconomic level. In the absence of a policy of regionalization of perinatal care, the discriminant factor for access to high level care (level 3 maternity site) is the socioeconomic level.

Maternal characteristics of women delivered of twins: natural vs. induced.

This study retrospectively compared sociodemographic and anthropometric data, as well as selected obstetric outcomes, of 13 mothers of twins who conceived after ovulation induction with clomiphene citrate or Pergonal with similar data from 255 mothers who conceived naturally. Infertile women were significantly (P < .011) older and likely to be married, of the white race, and more educated than women who conceived naturally. Treated women were also taller and heavier prior to conception (NS). Treated women gained significantly more weight (45.9 lb vs. 30.1 lb). They also had a higher proportion of gestations > 32 weeks (91.7% vs. 74.1%) and longer mean gestations (36.5 weeks vs. 35.4 weeks) compared to naturally conceiving mothers of twins, but neither of these differences was significant. The infants of treated mothers had birthweights 9.5% heavier than the infants of mothers who conceived naturally. These retrospective findings suggest that previously infertile women who conceive twins do not suffer worse reproductive outcome than women who conceive naturally.

The contribution of singletons, twins and triplets to low birth weight, infant mortality and handicap in the United States.

Among multiple gestations the magnitude of neonatal mortality, morbidity and postneonatal handicap is unknown. Although the proportion of multiple births has risen dramatically during the past decade, the proportion of total births in the United States is relatively small. The vast majority of multiples are low birth weight (LBW) or very low birth weight (VLBW), conditions that magnify both short-term and long-term risks. In this study, the risks for infant mortality and for postneonatal morbidity and handicap have been calculated from race-, plurality- and birth weight-specific mortality rates from the National Infant Mortality Surveillance (NIMS) Project and birth weight-specific postneonatal handicap rates from the Office of Technology Assessment report Healthy Children in proportion to the 1988 U.S. birth cohort. U.S. health objectives for the year 2000 for race-specific birth weight and infant mortality rates were used for comparison. Compared with that of singletons, twins' and triplets' relative risks for LBW are 10.3 and 18.8, respectively. Their relative risks for VLBW are 9.6 and 32.7. Compared with singletons, twins and triplets have relative risks for infant mortality of 6.6 and 19.4, respectively. For twins and triplets, postneonatal survivors' relative risks for severe handicap are 1.7 and 2.9 while those for overall handicap are 1.4 and 2.0, respectively. Recommendations for optimizing pregnancy outcomes in multiple gestations include liberalized weight gains, reduced physical effort and early, comprehensive prenatal care.

The costs of multiple pregnancy.

This paper reviews US vital statistics to describe the increase in multiple births in the United States between 1977 and 1987 and clarify the participation of differing maternal ethnic and age groups to this trend. The projected needs for NICU beds and costs of handicaps are estimated based on the distribution of low birthweights in multiple gestations. The potential methods of changing the distribution of low birthweight infants in multiple pregnancies are discussed.

The cost effectiveness of preventing preterm delivery in twin pregnancies.

As an extension of previous work on the risk of prematurity in singletons and on the social cost of twin births, an analysis has been carried out into the cost effectiveness of preventing premature delivery in twin pregnancies. The cost of prevention is assessed in terms of early diagnosis through ultrasound screening and of an extra 11 weeks of work leave to expectant mothers. When this cost is compared to the social cost involved in the transfer of newborns to neonatal intensity care units and in supporting handicapped children, it is concluded that the total cost of prevention corresponds to one-third of the long-term costs associated to lack of prevention.

The Yoruba contribution to our understanding of the twinning process.

The Yoruba people of Nigeria possess a twinning rate more than fourfold that of Caucasian populations. As such, they provide extraordinary possibilities for the study of multiple birth. Percy Nylander clarified many of the factors that contribute to this high incidence of twinning. His analyses of Nigerian placentation and zygosity have shown the increased rate of multiple pregnancy to be a result of higher proportions of dizygotic twins and trizygotic triplets as compared to Caucasian populations. Whereas a well-established genetic influence upon dizygotic twinning exists throughout the rest of the world, there may be an environmental factor in Nigeria responsible for the increased incidence of multiple births. Nylander's study of the Yoruba also has provided important contributions to the studies of perinatal mortality in multiple gestation. In totality, much of Nylander's work can be applied to further the understanding of ethnic and racial differences in human twin placentation and zygosity.

The Northwestern University Triplet Study. II: Fourteen triplet pregnancies delivered between 1981 and 1986.

Fourteen triplet deliveries conducted between 1 January 1981 and 30 June 1986 at the principal teaching hospitals of Northwestern University Medical School are reviewed. Maternal demographic characteristics are listed, as are the obstetric outcomes, including mode of delivery, and the fetal outcome. The recent literature of triplet delivery is reviewed. The rate of triplet delivery in our study was 0.37 per 1,000 live births. About two-thirds of the pregnancies resulted from the use of fertility-inducing agents. Ultrasonic confirmation was available in all cases. The majority of women were delivered by cesarean section (85%). No consistent pattern of presentation was seen. The mean weight of all 42 infants was 1,779 g (+/- 594). Unlike-sex triplets accounted for most of the sets (77%). The mean 5-min Apgar score of all infants was 9 and had no association with the order of deliveries. The weight differences by sex regardless of birth order were clinically insignificant. Neonatal mortality was 2.3%.

Economic considerations in the use of laparoscopy for diagnosing pelvic inflammatory disease.

The clinical diagnosis of pelvic inflammatory disease (PID) is associated with an average accuracy rate of 65% when preoperative impressions are confirmed or rejected with laparoscopy. The cost of this error rate should be evaluated when considering the cost and risks of immediate laparoscopy in patients suspected of having PID. This study reviewed selected patient admissions for PID from Northwestern Memorial Hospital for the years 1981-1985. The costs of hospitalization and treatment and the inherent diagnostic error rate were considered concurrently. No significant additional expense would have been incurred if all the women admitted with a clinical diagnosis of PID had had laparoscopic verification of their clinical diagnoses as compared to the cost of treatment with intravenous antibiotics for three to five days. We recommend the early use of laparoscopy in establishing the diagnosis of PID because it ensures a more accurate and definitive diagnosis and does not add significantly to costs.