Wednesday, June 4, 2008

In the News: Where is Birth Going & Who is Taking it There??!

Wow, has there ever been a bunch of coverage about birth in the news this week!

I came across the link to a NY Times article, "After Caesareans, Some See Higher Insurance Cost" on Navelgazing Midwife's blog earlier this week.

Basically, the article describes an emerging trend in insurance: that women who have had a Cesarean birth can either be refused coverage, or expected to pay a higher premium, unless the Cesarean included sterilization or they are otherwise less-likely to get pregnant (over forty years old, for example). This trend primarily applies to women who have individual insurance (not group insurance purchased through an employer), because insurers have more control over individual insurance prices.

I wonder how many women who are considering a Cesarean birth know that it may affect how much they pay for insurance, and/or how many choices they have for insurers later on down the road?

From the article: "'Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,' said Pamela Udy, president of the International Caesarean Awareness Network, a group whose mission is to prevent unnecessary Caesareans.

Although many women who have had a Caesarean can safely have a normal birth later, something that Ms. Udy’s group advocates, in recent years many doctors and hospitals have refused to allow such births, because they carry a small risk of a potentially fatal complication, uterine rupture. Now, Ms. Udy says, insurers are adding insult to injury. Not only are women feeling pressure to have Caesareans that they do not want and may not need, but they may also be denied coverage for the surgery.

'You have women just caught in the middle of this huge triangle of hospitals, insurance companies and doctors pointing the finger at each other,' Ms. Udy said."

To me, this seems like a feminist issue: with some doctors who don't adequately explain the risks/benefits of both Cesarean births and vaginal births and their potential long-term ramifications* and insurers who can choose to hike up their policies for an operation which a woman may have absolutely needed or have been pressured into (which would be worse? I don't even know!)... women are right in the middle, between the ACOG recommendations and money-hungry insruance companies.

For example, if a woman is having a breech baby, no matter how much she might research and decide that having an attended vaginal birth would be preferable to her than a Cesarean, if no providers in her area attend vaginal breech births - what does she do? She has a Cesarean or an unattended breech birth!

And where does this leave women who have already had a Cesarean and are giving birth again - what if there are no hospitals in their local area who do VBACs?? Here in central Maine, I'm only aware of a handful of hospitals who do VBACs: CMMC in Lewiston and MaineGen in Waterville. St. Mary's in Lewiston doesn't; Inland Hospital in Waterville doesn't; neither do MidCoast Hospital or Parkview in Brunswick. You can go all the way to Bangor or down to Maine Med in Portland, but otherwise, in the relatively sizeable area of central Maine, you only have two choices. So, the problem only gets sticker once a woman has a prior Cesarean, with choices getting narrower & narrower.

As Navelgazing Midwife mentions in her blog entry, I'm wondering where this trend - if/when enough women become aware of it - might take this country's ridiculously high rate of Ceasarean-births (about 1/3 of all births are Cesearean births), and whether it will have an impact on hospital's VBAC policies.

Further from the article: "Dr. Mary D’Alton, chief of obstetrics and gynecology at Columbia University Medical Center . . . said she was amazed to hear that insurers would charge higher premiums or deny coverage because of a past Caesarean. 'I would think if it’s happening, the medical profession has to take a stand,' Dr. D’Alton said."

What would "a stand" made by the ACOG on higher premiums for Cesarean births look like, I wonder? How could we encourage obstetricans to take such a stand?

To learn more about Cesarean births, visit Childbirth Connections Cesarean birth page.


Speaking of obstetricians, this article, "Giving Patients the VIP Treatment" from Time, reports on another interesting trend: family doctors and OBs who offer women "boutique" individualized prenatal/birth care, including longer appointments, 24/7 access to the doctor via phone or email, private childbirth classes, and a guarantee of attending the birth. AND... a bigger price tag: all of these add-ons also add on an additional $15,000 or so, in addition to the regular insurance co-pays.

Wait a minute, some women might say... the packaging of one-on-one, individualized, personalized care that includes wonderful "extras" like education, massage, house visits etc... that sounds awfully familiar... hold on, it's coming to me: homebirth midwives! Isn't that what they do?? Yes. Yes, it is. Except without the extra $15,000 pricetag!!!!

But what about safety? Well: many, many studies have shown that for low-risk pregnancies (which are the majority), attended homebirth is just as safe as a hospital birth (ask some people, and they'll tell you it's safer!). Check out this Citizens for Midwifery fact sheet on planned homebirth safety or this Index on Homebirth Resources or this Mothering Magazine Article: No Place Like Home.

What I find discouraging is that the Time article makes no mention of midwifery care and how similar it is to "boutique" care, without the hefty pricetag. Why not?


And now for the good news! For women who have a choice regarding which hospital they go to for their child's birth, there may soon be an easy way for her to compare her options: what is the hospital's episiotomy rate? the first-time Cesarean birth rate? breastfeeding rates at discharge? and more. To find out about this set of perinatal performance measures currently being put together by NQF (National Quality Forum), go here for the short version, or here for the long version.

Another group is working on a way to compare hospitals (and possibly caregivers, at some point): check out The Birth Survey project, which is online now for NYC as a pilot project and is working toward a national database this summer.

If you're wondering "why can't I just ask a hospital what their rates are on x or y, or what a caregiver's rates are?": I'll assume you've never tried. Sometimes it's possible, but it's rarely easy, especially if you're trying to get that kind of information at the beginning of your pregnancy in order to "comparison shop". Compiling this information in an accessible way would truly be revolutionary because it would enable women to "vote with their feet" by going to the hospital/caregiver whose care (not what they say they do, but what they actually do) best matches what that particular woman wants.

Have you heard or read anything interesting in the news re: pregnancy and birth lately?

*Wondering how a vaginal birth compares with a cesarean birth?? This is the kind of information which, in my opinion, would constitute informed consent:


Typically includes:

Stretching and stinging of the perineum while pushing.

If unmedicated, high levels of endorphins (natural morphine) for pain relief that lasts two weeks after the birth for mom.

Opportunity for immediate bonding and/or breastfeeding.

More choices: who is in the room with you during the birth, who cuts the cord, positions for birth, freedom after the birth.

Healthier start for baby.

Quicker physical recovery for mom.

Some possible risks:

More likely to experience pain in the vaginal area in the weeks and months after birth.

Though few women experience troubling symptoms beyond the postpartum period, there is a greater risk of urinary or bowel incontinence (more because of episiotomies and purple pushing).


Typically includes:

About twice as much blood loss as a vaginal birth.

Longer hospitalization.

Longer-lasting and more severe pain.

Less early contact with baby.

The risks of epidural, spinal or general anesthetic to mother and baby.

A four to six inch long permanent scar.

12 hours (or more) of IV, catheter and no eating after the baby is born.

Gas pain and bloating.

Cutting of seven layers of tissue and muscle.

Post-operative recovery room for 2-4 hours.

Some possible risks:

Higher risk of hemorrhage (severe bleeding).

Scarring and adhesions increase risk for ongoing pelvic pain and twisted bowel.

Limits choices for future births.

Higher risk for infection.

Mother is more likely to rate her birth experience poorly.

Increased challenges to start breastfeeding.

Baby at risk of being cut.

Baby (at 39 weeks or earlier) at higher risk of mild to serious lung and breathing problems.

Baby at greater risk for asthma later in life.

Puts woman at risk for developing complications during further pregnancies:
**ectopic pregnancy: pregnancies that develop outside her uterus or within the scar

**reduced fertility

**placenta previa: the placenta attaches near or over the opening to her cervix

**placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus

**placental abruption: the placenta detaches from the uterus before the baby is born

**rupture of the uterus: the uterine scar gives way during pregnancy or labor.

Puts babies from future pregnancies at risk:
**of being born too early (preterm)

**of low birthweight

**of dying before or shortly after the birth.

Most of this information was compiled from Best Evidence: C-Section, on Childbirth Connection - they include even more risks on their list, with more details. There's also C-Section Myth vs. Reality, which is interesting too.

This statement will probably be obvious, but I'll include it just in case: even with all the additional risks Cesarean births are an important tool that can save the lives of women and babies. It's just that study after study and statistic after statistic suggest that our country's national rate of Cesarean (31-ish%) increases the mortality and morbidity of women and babies instead of protecting them. While Ceseareans are critical to the safe birth of a few babies and their mothers, I believe they are only necessary a fraction of the time they are currently performed in this country. For example, The Healthy People 2010 report included achieving an overall national rate of cesarean birth of 15% (good luck with that!). Ina May Gaskin's community reports a cesarean birth rate of less than 2%, while maintaining excellent mother/baby outcomes.

Christina @ Birthing Your Baby
Independent Childbirth Classes in Central Maine

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