Enrollment is down sharply on the federal health insurance marketplace this fall, and the consumer assistance groups that help with sign-ups think they know why.

They don’t have the staff to help as many customers as before because the Trump administration slashed funding. The federal government is spending $10 million this year on navigators who help individuals enroll in coverage. The government spent $36 million in 2017 and $63 million in 2016.

“We don’t have the people to provide the enrollment assistance nor to do the outreach and marketing to let people know what’s happening,” says Jodi Ray at the University of South Florida. She’s overseen Florida’s largest navigator program since 2014.

Ray’s program received $1.2 million in federal funding this year, down from $5 million a year ago. Florida leads the nation in enrollment in the Affordable Care Act marketplace plans.

With less money, Ray can afford to pay only 59 navigators across the state this year, down from 152 a year ago. With fewer navigators, much of the group’s counseling is done by phone instead of in person. That complicates the job, she says, because it is much easier to talk with customers in person, while looking at dozens of health plans with different costs and benefits.

Open enrollment in the Obamacare plans began Nov. 1 and will run until Dec. 15 for the 39 states covered by the federal exchange, HealthCare.gov. The other exchanges — run by states — typically extend sign-ups until the end of December or into January.

All these health plans sold under the Affordable Care Act are for people who don’t get coverage via their workplace or the government.

Nationwide, navigator groups are scrambling to make up for the loss of federal funding to ensure they can help people make sense of their health insurance options.

• In South Carolina, the Palmetto Project has transformed into the state’s first nonprofit insurance agency. Several of its former federally funded navigators are now licensed insurance agents. In their new role, they get paid a commission on their sales and don’t have to follow Trump administration rules that encourage navigators to talk to customers about short-term plans with limited benefits. The agents can also help customers enroll in Medicaid, Medicare and individual plans not sold on the ACA exchange.
• The Community Council of Greater Dallas, which was funded last year to help with enrollment in 56 counties, has raised money from private donors to continue serving the seven counties around Dallas. But it has 25 fewer navigators, so consumers seeking help must wait three days on average, compared with less than a day last year. Across Texas, 211 of 254 counties have no federally paid navigators.
• In Wisconsin, the organization Covering Wisconsin has raised millions of dollars from cities, counties and local United Way chapters, as well as the state Medicaid agency, to make up for the federal cuts. Even still, the group will be able to provide in-person assistance in only eight counties around Milwaukee and Madison. Twenty other counties are served by telephone.
• The Kansas Association for the Medically Underserved is relying completely on volunteers to help consumers with in-person and telephone assistance. In the past year, the association was able to use government funding to pay about 20 navigators.

Nationally, nearly 800 counties served by the federal marketplace will not have any federally funded navigators this fall — up from 127 counties in 2016, according to the Kaiser Family Foundation.

Federal officials say they are not providing funds for navigators in Iowa, Montana or New Hampshire because no organizations applied in those states.

Nearly 12 million people across the country — including nearly 9 million on the federal exchange — enrolled in Obamacare plans for 2018.

In the first 17 days of open enrollment, 1.9 million people chose a plan for the 2019 coverage year on HealthCare.gov, according to data released last week by the federal Centers for Medicare & Medicaid Services. That compares with nearly 2.3 million consumers who selected their coverage through the exchange during the first 18 days last year.

States with the largest enrollment drops include Pennsylvania (down 29 percent from last year), Missouri (down 27 percent) and Virginia (down 42 percent).

The annual enrollment tally is being closely followed, in part because 2019 marks the first year since the marketplace plans began in 2014 that Americans won’t be fined for failing to have health coverage.

But health insurance specialists think the lack of navigator funding could end up having a bigger impact on enrollment. Caroline Gómez-Tom, navigator program manager of Covering Wisconsin, says the end of the individual mandate penalty has been a “nonissue” among people seeking coverage.

“Some folks mention it, but at the end of the day they still walk away with health coverage,” she says. “The ability to have coverage at affordable prices outweighs the penalty being gone, because people still see health care insurance as important to have.”

Consumers generally have a greater choice of plans for 2019 as more companies enter the individual market and existing plans expand their areas of service. Plus, insurance premiums are dropping in some areas. And where they are rising, the rate of increase is among the lowest in several years.

Katrina McGivern, director of policy and public affairs for the Kansas Association for the Medically Underserved, says people in rural areas of the state will have the most difficulty getting help, as a result of funding cuts.

After five years of experience, she says, she is hopeful that people will be able to figure out how to sign up on their own.

Still, she adds, “we always see a need for people who need assistance to get through it.”

Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente.

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Shereese Hickson’s multiple sclerosis was flaring again. Spasms in her legs and other symptoms were getting worse.

She could still walk and take care of her son six years after doctors diagnosed the disease, which attacks the central nervous system. Earlier symptoms such as slurred speech and vision problems had resolved with treatment, but others lingered: She was tired and sometimes fell.

This summer, a doctor switched her to Ocrevus, a drug approved in 2017 that delayed progression of the disease in clinical trials better than an older medicine did.

Genentech, a South San Francisco, Calif.-based subsidiary of Swiss pharmaceutical giant Roche, makes Ocrevus. The drug is one of several for multiple sclerosis that are delivered intravenously in a hospital or clinic. Such medicines have become increasingly expensive, priced in many cases at well over $80,000 a year. Hospitals delivering the drugs often make money by charging a premium on top of their cost or adding hefty fees for the infusion clinic.

Hickson received her first two Ocrevus infusions as an outpatient two weeks apart in July and August. And then the bill came.

Patient: Shereese Hickson, 39, single mother who worked as a health aide and trained as a medical coder, living in Girard, Ohio. Because her MS has left her too disabled to work, she is now on Medicare; she also has Medicaid for backup.

Total bill: $123,019 for two Ocrevus infusions taken as an outpatient. CareSource, Hickson’s Medicare managed care plan, paid a discounted $28,960. Hickson got a bill for about $3,620, the balance calculated as her share by the hospital after the insurance reimbursement.

Medical service: Two Ocrevus infusions, each requiring several hours at the hospital.

Service provider: Cleveland Clinic, a nonprofit, academic medical center based in Ohio. (Cleveland Clinic has provided financial support for NPR.)

What gives: Hickson researched Ocrevus online after her doctor prescribed the new medicine. “I’ve seen people’s testimonies about how great it is” on YouTube, she said. “But I don’t think they really go into what it’s like receiving the bill.”

That was particularly shocking because, covered by government insurance for her disability, she had never received a bill for MS medicine before.

“I have a 9-year-old son and my income is $770 a month,” said Hickson. “How am I supposed to support him and then you guys are asking me for $3,000?”

Even in a world of soaring drug prices, multiple sclerosis medicines stand out. Over two decades ending in 2013, costs for MS medicines rose at annual rates five to seven times higher than those for prescription drugs generally, found a study by researchers at Oregon Health & Science University.

“There was no competition on price that was occurring,” said Daniel Hartung, the OHSU and Oregon State University professor who led the study. “It appeared to be the opposite. As newer drugs were brought to market, it promoted increased escalation in drug prices.”

With Ocrevus, Genentech did come up with a price that was slightly less than for rival drugs, but only after MS medicines were already extremely expensive. The drug launched last year at an annual list price of $65,000, about 25 percent lower than that of other MS drugs, Hartung said. MS drugs cost about $10,000 per year in the 1990s and about $30,000 a decade ago.

“We set the price of Ocrevus to reduce price as a barrier to treatment,” said Genentech spokeswoman Amanda Fallon.

It was also probably a response to bad publicity about expensive MS drugs, Hartung said. “Now companies are very aware at least of the optics of releasing drugs at higher and higher prices,” he said.

Patients starting Ocrevus get two initial infusions of 300 milligrams each and then 600 milligrams twice a year. Cleveland Clinic charged $117,089 for Hickson’s first two doses of Ocrevus — more than three times what hospitals typically pay for the drug, said John Hennessy, chief business development officer at WellRithms, a firm that analyzes medical bills for self-insured employers.

As is typical of government programs such as Medicare, the $28,960 reimbursement ultimately collected by the Cleveland Clinic was far less — but still substantial.

“We kind of got ourselves in a pickle here,” he said. “We’re more excited about the discount than we are about the actual price.”

Hickson’s nearly $3,620 bill represented the portion that Medicare patients often are expected to pay themselves.

Last year, the Institute for Clinical and Economic Review, an independent nonprofit that evaluates medical treatments, completed a detailed study on MS medicines. It found that Ocrevus was one of three or four medicines that were most effective in reducing MS relapses and preventing MS from getting worse. But it also found that patient benefits from MS drugs “come at a high relative cost” to society.

At the same time, deciding which MS drug — there are about a dozen — would best suit patients is something of a shot in the dark: The science showing the comparative effectiveness of MS drugs is not as strong as it could be, researchers say.

“In general, there’s a real lack of head-to-head studies for many of these drugs,” said Hartung. The [Food and Drug Administration] has no required comparison standard for MS drugs, an agency spokeswoman said. Sometimes they’re rated against placebos. With everyone able to charge a high price, the companies have little incentive to see which works better and which worse.

Resolution: After Hickson questioned the charges over the phone, the billing office told her to apply to the hospital for financial assistance. Hickson had to print a form, provide proof of her disabled status, mail it and wait.

Hospital officials told her in October she qualified for assistance based on her income through a state program funded by hospital contributions and federal money. Cleveland Clinic wiped out the $3,620 balance.

“I’m grateful that they approved me for that, but not everybody’s situation is like that,” she said. She was worried enough about being billed again for her next Ocrevus infusion that she considered switching back to her old medicine. But her doctor wants her to give it more time to gauge its effects.

The takeaway: Always ask about charity care or financial assistance programs. Hospitals have different policies and wide discretion about how to apply them, but they often do not even tell patients such programs exist.

Because health care costs can be so high, you may be eligible even if you have a decent salary. Cleveland Clinic gives free care to everybody below a certain income, said spokeswoman Heather Phillips. But it wasn’t until Hickson called that the hospital agreed to erase the charge.

While there are multiple new drugs to treat serious chronic conditions, they have often not been tested against one another. Moreover, your doctor may have no idea about their prices. But he or she should.For newer drugs, all options may well be very expensive.

Keep in mind that drugs that must be infused often come with facility fees and infusion charges, which can leave patients with hefty copayments for outpatient treatment. Ask about oral medicines or those you can self-inject at home.

NPR produced and edited the interview with Kaiser Health News’ Elisabeth Rosenthal for broadcast. Marlene Harris-Taylor, from member station Ideastream in Cleveland, provided audio reporting.

Do you have an exorbitant or baffling medical bill that you’d like KHN and NPR to look into? You can tell us about it and submit a copy of the bill here.

KHN is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that isn’t affiliated with Kaiser Permanente.

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Doctors who are opposed to abortions, don’t have to provide them. Since the 1970s, a series of federal rules have provided clinicians with “conscience protections” that help them keep their jobs if they don’t want to perform or assist with the procedure.

Religious hospitals are also protected. Catholic health care systems, for example, are protected if they choose not to provide abortions or sterilizations. Doctors who work for religious hospitals usually sign contracts that they’ll uphold religious values in their work.

But as the reach of Catholic-affiliated health care grows, these protections are starting to have consequences for doctors who do want to perform abortions — even as a side job.

Religious hospitals often prohibit their doctors from performing abortions — even if they perform those abortions at unaffiliated clinics, says Noel León, a lawyer with the National Women’s Law Center. She was hired about two years ago to help physicians who want to be abortion providers. They have little in the way of legal protection, she says.

“Institutions are using the institutional religious and moral beliefs to interfere with employees’ religious and moral beliefs,” León says.

This kind of legal argument, León says, may prevent doctors from providing care they feel called to offer. And since many clinics that provide abortions rely heavily on part-time staff, it may also prevent these clinics from finding the doctors they need to stay open.

Dr. Kimberly Remski sought help from León when she was job-hunting. She is a primary care physician but had always been interested in women’s health. When she first set foot in a clinic that provides abortions, she realized it was her passion.

“A lot of the things we spend our time doing in training are monotonous, or you’re getting swamped in work,” she says. “I just remember leaving the clinic feeling like I was doing something really important.”

She interviewed for a job as a primary-care doctor with IHA, one of the largest physician groups in Michigan in 2017. She says she was clear about her desire to work one day a week in an independent clinic that provides abortions.

Part-time work is common for outpatient physicians, and Remski says the doctors she interviewed with were receptive.

“I was very upfront. I told that them that was a special interest of mine. I wanted to be able to pursue it,” she says.

She signed a contract, and started preparing for her move. Then she got a call that the offer was off.

Remski learned that her potential employer was actually owned by a larger Catholic hospital network called Trinity Health, and it requires physicians to “provide services in a manner consistent with the Ethical and Religious Directives for Catholic Health Care Services,” according to her contract.

And, she says, she was shocked to learn Trinity Health would also have had a say over how she spent her free time. IHA officials told her that she couldn’t work on the side as an abortion provider if she took the job, Remski says.

Trinity Health had merged with IHA in 2010, part of a wave of mergers that has led to a net increase in Catholic ownership of hospitals. According to a 2016 report from MergerWatch, an organization that tracks hospital consolidation, 14.5 percent of acute care hospitals are Catholic-owned or affiliated. That number grew by 22 percent between 2001 and 2016, while the overall number of acute care hospitals dropped by 6 percent.

And as Catholic-affiliated health care expands, says León, doctors increasingly encounter morality clauses that prohibit them from performing abortions.

León says she has worked with at least 30 physicians and nurse practitioners from 20 different states who faced problems similar to Remski’s when they disclosed to their employers, or potential employers, that they planned to provide abortions.

“They’re being told that, ‘We can’t provide the care we went into medicine to provide,’ ” León says. “We shouldn’t be putting providers in the position of caring for their patients or keeping their jobs.”

Representatives of IHA would not agree to a phone interview about Remski’s situation, but spokesperson Amy Middleton explained in an email that IHA “works hard with our physicians to enable them to pursue other positions.” But, she added, “outside work that interferes with a physician’s ability to serve patients or contradicts the organization’s practices could present a conflict of interest.”

IHA physicians follow Catholic health care guidelines, Middleton wrote, which requires that physicians “not promote or condone contraceptive practices.”

Dr. Barbara Golder, the editor of the Catholic Medical Association journal the Linacre Quarterly, says that language about morality is ubiquitous in contracts — and that it’s reasonable that religious institutions might not want to be associated with abortion providers.

“The person is seen primarily as Dr. X of Catholic hospital Y, and then it turns out that Dr. X of Catholic hospital Y is doing abortions on the weekends,” Golder says. “There’s sort of a cognitive dissonance about that. It’s in opposition to what Catholic health care is.”

According to Lance Leider, a Florida attorney who has reviewed hundreds of physician contracts, it is “exceedingly common” for contracts, not just at religiously-affiliated hospitals, to include language about the reasons an employer can fire a doctor, including but not limited to morality clauses.

“There’s always a laundry list of things the employer can terminate the contract for,” Leider says. “There’s usually a catch-all. Anything that calls into question the reputation of the practice.”

These clauses tend to be vague, León adds, which means employers can invoke them to prevent a wide range of activities, like political activity, controversial posts on social media, or, in religious hospitals, physicians spending time at clinics that provide abortions.

The restrictions may have ramifications not only for physicians, but for many clinics that provide abortions. Smaller clinics may be staffed almost entirely with part-time doctors, and when they can’t find enough, they’re sometimes left unable to meet the demand for services.

“We don’t have full-time doctors,” says Shelly Miller, the executive director of Scotsdale Women’s Center in Detroit, Mich., one of the clinics where Remski worked. “We really cannot afford to have a provider sit here all day and wait for patients to come in.”

Through her involvement with the National Abortion Federation, Miller often talks with other directors of small clinics that provide abortions, and sometimes other women’s health services. She says that many of her counterparts say they exclusively hire part-time physicians because they simply don’t need somebody full-time. If more physicians are prohibited from part-time abortion work, Miller worries it may put some smaller clinics out of business.

It’s hard to know exactly how many of these clinics primarily use part-time staff, according to Rachel Jones, who studies the demographics of U.S. abortion services at the Guttmacher Institute, a family planning research organization. Ninety-five percent of abortions take place in clinics as opposed to hospitals, Jones notes, which may be more likely to utilize a team of part-time staff.

León doesn’t have data to show how common it is for physicians to be threatened with termination for providing abortions. She guesses that doctors will either give up on providing abortions — or, like Remski did, look for a different job that allows them to. León spends much of her time speaking to groups of doctors about how to approach contract negotiation if they want to provide abortions.

Ultimately, Remski says she parted amicably from IHA, since “it felt like the wrong place for me.”

She ended up finding a job at an urgent-care clinic in Michigan, which allowed her to work part-time at three separate clinics that provide abortions. She has since moved to Chicago, where she also splits her time between providing abortions and primary care.

“I was providing a service that was needed and necessary,” Remski says. “I realized it was something I really needed to do.”

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.

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Named from the Greek kloster, for spindle, a class of bacteria known as Clostridia abounds in nature.

Staining deep violet under the microscope, they appear as slender rods with a bulge at one end, like a tadpole or maple seed. They thrive in soil, marine sediments and humans. They live on our skin and in our intestines.

And sometimes, they can kill you.

Most strains are harmless, but tetanus, botulism and gangrene are caused by clostridial species. Vaccination, sanitation and improved medical care have made these infections less common, but one variety has been difficult to contain.

Clostridium difficile, or C. diff, can cause diarrhea and a life-threatening infection of the intestines. The bug was associated with nearly 30,000 deaths in 2011.

First seen as a problem mainly confined to hospitals and nursing homes, research suggests C. diff rates in the community are on the rise, and that traditional risk factors may no longer tell the whole story.

C. diff was discovered in 1935 by scientists in Denver in the intestinal flora of healthy infants. The bacterium was harmless to the infants but proved lethal when injected into rabbits, providing an early clue to its danger.

At the same time, scientists in the United Kingdom were pioneering the use of penicillin to treat bacterial infections. The drug’s efficacy was near miraculous, but some patients developed severe diarrhea as a side effect. As antibiotics became widely available in the 1950s, this adverse effect became more common.

Early researchers speculated that Staphylococcus aureus, a common pathogen, was the cause. The usual treatment for staph is the antibiotic vancomycin, and many patients improved. But the true cause was C. diff — it was a stroke of simple luck that vancomycin is effective against both.

In 1974, scientists in Cincinnati discovered a toxin in affected patients’ stool, and traced it to C. diff.

A surge of interest in C. diff followed, and investigators quickly determined risk factors for the disease. Antibiotic use was already known, but hospitalization emerged as another dominant factor — so much so that C. diff became known almost exclusively as a hospital-acquired infection.

Clostridial species can revert to hardy spores that resist disinfectants, which is why so many infections occurred in hospitals and nursing homes. Health care workers were unknowingly spreading the spores and inoculating patients.

Scientists also began to ask why antibiotics triggered the infection. The answer appeared to be simple ecology. In healthy intestines, the sheer diversity of bacteria meant that C. diff couldn’t establish a foothold for out-of-control growth. But once a round of antibiotics had purged the normal flora, C. diff could take over.

Improved infection control in hospitals began to cut infection rates, but a few studies suggested that the problem might be bigger than anyone realized.

In 1991, Australian scientists found that C. diff was responsible for 5.5 percent of outpatient diarrheal infections, and researchers in Boston published additional evidence of community-acquired C. diff in 1994. Subsequent work confirmed the existence of C. diff in the community but suggested that the prevalence was low.

Things changed in 2006, when a hospital in North Carolina reported that 35 percent of C. diff infections were occurring outside the hospital, and that only half could have involved antibiotic exposures. A Centers for Disease Control and Prevention investigation, using different methods, found that 20 percent of infections had no recent health care exposure and only half had antibiotic exposure.

Work published in 2011 found that 40 percent of all C. diff infections in southern Minnesota were community-associated. Even more concerning, the investigators noted a marked increase over time of community-associated C. diff.

The CDC estimated that nearly 350,000 C. diff infections occurred outside of hospitals in 2011, and found that 46 percent were fully community-acquired and 36 percent had no antibiotic exposure. And just last year, researchers in California found that 1 in 10 emergency room patients with diarrhea tested positive for C. diff, and that 40 percent had no risk factors at all.

Traditional risk factors — antibiotics and hospitalization — can no longer explain many infections. Scientists have long suspected that antibiotics trigger C. diff infections by disrupting the intestinal microbiome.

Could it be that other factors are having a similar effect? Is our microbiome growing more susceptible to these dangerous infections?

Dr. Alice Guh, a researcher with the CDC, thinks so. “There’s definitely something going on,” she says, “but we don’t fully understand what.”

Diet strongly influences the microbiome and could be an element, she says. A recent study found that trehalose, a common food additive, markedly enhances the virulence of C. diff, although Guh cautions that there have been difficulties replicating the findings.

Guh thinks some common medications could be involved, too. Popular drugs for heartburn that suppress acid in the stomach are associated with C. diff infections, and have been shown to disrupt the microbiome.

And in March a study in Nature evaluated the effects of a thousand non-antibiotic medications on friendly bacteria in the human colon and found that 25 percent had antimicrobial activity.

Rising rates of C. diff infection in the community are a major public health concern. But could they be a sign of an even larger problem—that our guts are becoming ever more fragile? Scientists have already uncovered links between changes in the microbiome and a slew of other human diseases.

Perhaps C. diff is just a canary in the mine.

Clayton Dalton is a resident physician at Massachusetts General Hospital in Boston.

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The tiny hand and forearm slipped out too early. Babies are not delivered shoulder first. Dr. Terri Marino, an obstetrician in the Boston area who specializes in high-risk deliveries, tucked it back inside the boy’s mother.

“He was trying to shake my hand and I was like, ‘I’m not having this — put your hand back in there,’ ” Marino would say later, after all 5 pounds, 1 ounce of the baby lay wailing under a heating lamp.

This is the story of how that baby, Bryce McDougall, tested the best efforts of more than a dozen medical staffers at South Shore Hospital in Weymouth, Mass., one day last summer.

Bryce’s birth also put to the test a new method of reducing cesarean sections that has been developed at Dr. Atul Gawande’s Ariadne Labs, a “joint center for health systems innovation” at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health in Boston.

The story starts before Bryce’s birth, on the last day of August at about 9:30 in the morning.

Melisa McDougall has just checked into South Shore, after a routine ultrasound. She’s in her 36th week, pregnant with twin boys. The doctors have warned Melisa that her placenta won’t hold out much longer. She’s propped up in bed, blond hair pulled into a neat bun, makeup still fresh, ordering a sandwich, when her regular obstetrician arrives.

“How are you?” asks Dr. Ruth Levesque, sweeping into the room and clapping her hands. “You’re going to have some babies today! Are you excited?”

The first of the twins — Brady — is head-down, ready for a normal vaginal delivery. But his brother, Bryce, is horizontal at the top of Melisa’s uterus.

That’s one reason Melisa is a candidate for a C-section. Babies do not come out sideways. And there’s another reason most doctors would never consider a vaginal delivery in Melisa’s case, Levesque says. Four years ago, she delivered the twins’ sister by cesarean.

“[Melisa] has a scar on her uterus,” Levesque explains, “so there’s a risk of uterine rupture — very rare, but there’s always a possibility.”

And that possibility may be greater for Melisa because she’s 37 years old and having twins. But the McDougalls hope to have vaginal deliveries for both boys.

“I just feel like it’s better for the kids — better for the babies,” Melisa says.

How the Team Birth Project came to be

Avoiding C-sections is also better for many moms. With cesareans, there’s a longer recovery period, a greater risk of infection and an association with injury and death. And most are not medically necessary, says Dr. Neel Shah, who directs the Delivery Decisions Initiative at Ariadne Labs.

“We’re fairly confident that, when you look nationally, the plurality — if not the majority — of C-sections are probably avoidable,” says Shah.

Those avoidable C-sections are the focus of the Team Birth Project, designed by Shah with input from roughly 50 doctors, nurses, midwives, doulas, public health specialists and consumer advocates who focus on childbirth. South Shore Hospital is one of the pilot sites for the project.

In describing the collaboration, Shah begins with an acknowledgement: Childbirth is complicated. You’ve got two patients — the mother and the baby — and an ad hoc, often shifting team that at a minimum includes the mom, a nurse and a doctor.

“So you’ve got three people who have to come together and become a very high-performing team in a really short period of time, for one of the most important moments in a person’s life,” Shah says.

And this team has to perform at its best during an unpredictable event: labor.

Shah says doctors and nurses generally agree about three things: when a mom is in active labor; when a mom can definitely try for a vaginal delivery; and when she must have a C-section.

“And then there’s this huge gray zone,” Shah says. “And actually, everything about the Team Birth Project is about solving for the gray.”

To avoid unnecessary C-sections when what to do isn’t clear, this hospital, in conjunction with the Ariadne project, has changed the way labor and delivery is handled from start to finish.

First, women aren’t admitted until they are in active labor. Secondly, the mom’s preferences — such as whether she would like an epidural or not and whether she wants to have “skin-to-skin contact” with the baby immediately after birth — help guide the members of the labor team. The team members map the delivery plan — including Mom’s preferences and the medical team’s guidance — on a whiteboard, like the one in Melisa’s room.

For the births of Bryce and Brady McDougall, the white erasable planning board gets a lot of use.

Under “team,” Dr. Levesque and registered nurse Patty Newbitt write their names. Melisa and Shaun McDougall are also listed as equal partners. The names of other family members or nurses may be added and erased as labor progresses. Shah’s idea is that this team will “huddle” regularly throughout the labor to discuss the evolving birth plan.

The birth plan itself is divided into three separate elements on the board: maternal (the mom), fetal (the baby) and progress (in terms of how the labor is progressing). A mom with high blood pressure may need special attention — and that would be noted on the board — but she could still have a normal labor and vaginal delivery.

Good communication is key

Dr. Kim Dever, who chairs the OB-GYN department at South Shore, highlights a section of the whiteboard called “Next Assessment.”

That category is included on the board, Dever says, “because one of the things I often heard from patients is that they didn’t know what was going to happen next. Now they know.”

Asking the mom — and the couple — about their preferences for the delivery is crucial, too, Levesque says.

“It forces us to stop and to think about everything with the patient,” she explains.”It makes us verbalize our thought process, which I think is good.”

Shaun McDougall walks across the room to get a closer look at the whiteboard.

“Honestly, it seems like common sense,” he says. “I would always think the nurses would have something like this, but to have it out where mom and dad can see it — I think it’s pretty cool.”

With Melisa McDougall’s plan in place, everyone settles in, to wait. About four hours later, Melisa isn’t yet feeling contractions. Levesque breaks the water sac around Brady.

“Looks nice and clear,” Levesque reports. “Hey bud, come on and hang out with us,” she says to the baby, tickling his head.

“So, you’re going to keep leaking fluid until you leak babies,” the doctor explains to Melisa. “Whenever you start getting uncomfortable, we’ll get you an epidural at that point.”

Levesque moves to the board and adds updates: Melisa is 4 centimeters dilated; her waters broke at 13:26; the next assessment will be after she gets an epidural.

The medical team insisted ahead of time that Melisa agree to be numbed from the waist down if she wants to deliver Bryce — the second twin — vaginally. Melissa agreed. The obstetricians may need to rotate the baby in her uterus, find a foot and pull Bryce out, causing pain most women would not tolerate.

One of those doctors — Marino — peeks into the room and waves.

“Just came to say hi,” says Marino, who has more experience than most obstetricians in delivering babies positioned like Bryce. Along with Levesque, Marino has been seeing Melisa regularly in office visits.

Shaun McDougall asks the physicians if they’ll pose for a picture with his wife.

“Can we make funny faces?” asks Levesque.

“I want you to,” says Shaun. “You guys are like her favorite people on the planet.”

As the hours tick by, there’s a shift change, and registered nurse Barbara Fatemi joins the McDougall team. She checks Melisa’s pain level regularly to determine when she’s ready for the epidural.

Melisa says she isn’t feeling much but adds that she has a high tolerance for pain. Shaun tells Fatemi he sees the strain on his wife’s face. Fatemi acts on Shaun’s assessment and calls an anesthesiologist to prepare the epidural, something Shaun later says reinforces his feeling that they’re a team.

Levesque soon arrives for the promised “next assessment.” Melisa is now 10 centimeters dilated and ready to deliver — but she must hold on until nurses can get her into an operating room.

Levesque will still attempt to deliver both babies vaginally, she explains, but in the operating room, Melisa will be in the right place if Bryce doesn’t shift his position inside the uterus, and the doctor needs to do a last-minute cesarean.

“I’ll see you in a few minutes. No pushing without me, OK?” Levesque says over her shoulder as she heads to the operating room to prep.

“I’ll try,” Melisa says, weakly. In a minute, nurses are rolling her down the hall, following Levesque.

Almost five years ago, two women who were wheeled into this hospital’s operating rooms during childbirth died after undergoing C-sections. Though state investigators found no evidence of substandard care, Dever says the hospital scrutinized everything.

“When you have something like that happen, that expedites your efforts,” she says. “Exponentially.”

Now, Dever says, she sees an opportunity, through the Team Birth Project, to model changes that could help women far and wide.

“I would love women everywhere to be able to come in and have a safe birth and healthy baby,” she says. “That’s why I’m doing it.”

“They did not flinch”

Dever is about to see her pilot study of the Team Birth Project pushed to new limits by little Bryce McDougall. First, though, Melisa must deliver Bryce’s brother, Brady. Even his birth, the one that was expected to be easier, is more difficult than anticipated.

Bent nearly in half, her face beet red, Melisa strains for five pushes. She throws up, then gets back to laboring. And suddenly, there he is.

“Oh my goodness, Brady, oh Brady,” wails Shaun. He follows a nurse holding his son over to a warmer.

Marino takes Shaun’s place next to Levesque, who has reached inside Melisa to get the next twin. Levesque’s mission is to grab Bryce’s feet and guide him out. But everything feels like fingers, not toes.

“That’s a hand,” she murmurs. “That’s a hand, too.”

Marino rolls an ultrasound across Melisa’s belly, hoping the scan will show a foot. But Bryce’s feet are out of sight and out of reach.

Marino has had more experience than most obstetricians with transverse babies, and this procedure, known as a breech extraction; she asks to try. She reaches into Melisa’s uterus while Levesque moves to Melisa’s right side and uses her forearm to shift Bryce and push him down. Dever, the head of obstetrics, has come into the room and takes over the ultrasound. At least six doctors and nurses encircle Melisa, whose face is taut. Shaun frowns.

“Babe, you OK?” he asks.

Melisa nods. Bryce’s heart rate is steady. But there’s still no sign of a foot. One little hand slips out and Marino nudges it back in.

“Open the table,” says Marino, her voice strained.

It’s open and ready, her colleagues say, referring to the array of sterile surgical instruments that Marino may soon need, to begin a C-section.

For 36 seconds, this room with more than a dozen adults grows oddly quiet. Everyone is watching Marino twist her arm this way and that, determined to find Bryce’s feet. Levesque leans hard into Melisa’s belly. Shaun bites his lip. Then Marino yanks at something — and her gloved, bloodied hand emerges, clenching baby Bryce by his two teeny legs.

“Oh babe, here he comes, here he comes — Woo!” squeals Shaun.

Shaun is overcome with emotion again. Melisa manages an exhausted giggle. Baby Bryce keeps everyone waiting a few more seconds and then howls.

Levesque starts to stitch up a small tear for Melisa, and Marino comes around to congratulate the new mom.

“He was fighting you, huh?” Melisa says, and laughs.

Outside the operating room, Levesque and Marino look relieved and elated. Both agree that most doctors would have delivered Bryce by C-section. But at South Shore, the McDougalls found a hospital that has challenged itself to perform fewer C-sections and a doctor with experience in these unusual deliveries — one who knew and respected the parents’ preference.

“They specifically wanted to have a vaginal delivery of both babies,” Marino says — and that was on her mind during the difficult moments.

Bryce was fine, says Marino, so the deciding factor for her was that Shaun and Melisa did not panic.

“They did not flinch — they were like, ‘Keep going,’ ” Marino recalls. “Sometimes the patient will say ‘stop,’ and then you have to stop.”

The babies’ father says he came close to requesting that, in the very last minute before Bryce was born.

“That part with the arm — it was pretty aggressive,” Shaun says.

But in that moment, he adds, the feeling that he and Melisa were part of the team made a difference.

“It made us more comfortable,” Shaun says, and that comfort translated to trust. “We trusted the decisions they were making.”

Melisa says she’s grateful for the vaginal delivery.

“I did not want to have a natural birth and a C-section,” she says. “That would be a brutal recovery.”

Instead, 30 minutes after Marino pulled Bryce out of her, Melisa is nursing Brady and talking with family members via FaceTime.

Next assessment for The Team Birth Project

South Shore began using the Team Birth approach in April. Three other hospitals are also pilot sites: Saint Francis in Tulsa, Okla.; EvergreenHealth in Kirkland, Wash.; and Overlake in Redmond, Wash. The test period runs for two years. In the first four months at South Shore, the hospital’s primary, low-risk C-section rate dropped from 31 percent to 27 percent — about four fewer C-sections each month.

Experts who contributed to the development of the Team Birth Project are anxious to see whether other hospitals can lower their rates of C-section and keep them down.

“Once you get past the early adopters, how do you demonstrate the benefits for others that aren’t willing to change?” asks Gene Declercq, a professor of community health sciences at Boston University School of Public Health.

Declercq notes that a few insurers are beginning to force that question, refusing to include in their networks hospitals that have high C-section rates, or high rates of other unnecessary, if not harmful, care.

Declercq says the project’s focus on communication in the labor and delivery room makes sense because many physicians decide when to perform a cesarean based on clinical habit or the culture of their hospital.

“If you can impact that decision-making process, you can perhaps change the culture that might lead to unnecessary cesareans,” says Declercq.

The federal government has set a target rate for hospitals: No more than 23.9 percent of first-time, low-risk mothers should be delivering by C-section. The U.S. average in 2016 was 25.7 percent.

The target was put in place because research has shown that if a woman’s first delivery is a C-section, her subsequent deliveries are highly likely to be C-sections, too — raising her (and her baby’s) risk for complications and even death.

This story is part of NPR’s reporting partnership with WBUR and Kaiser Health News.

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