The Birth - Insurance Relationship and Ways to Avoid a C-section

Before I became involved in the prenatal yoga and childbirth education world, I associated childbirth with a cute cuddly baby, happy parents and fuzzy teddy bears. Now, I think technology, defensive medicine and insurance issues. Hmm…I don’t really like that shift, but it does ring true to reality.

Our national cesarean rate has increased 50% in the last decade, with about 1/3 of expectant mother’s now delivering via cesarean section. This rate is twice as high as the WHO (World Health Organization) recommends. However, many think: “Well, with this technology we must be having healthier, safer births.” NOT TRUE! Unfortunately, the American public in general (physicians included) has a false sense of security about the safety of C-sections because the statistics on maternal death in the UNITED STATES are misleading. According to the Centers for Disease Control (CDC), the number of maternal deaths in the United States is probably up to three times as high as the number reported in our national statistics because not all maternal deaths are classified as pregnancy-related on the death certificate.

If we are not seeing a healthier turn-out with cesarean births, why has the c-section rate skyrocketed? The answer is simple: time and money. The average uncomplicated cesarean runs about $4,500, nearly twice as much as a comparable vaginal birth, and cesareans account for a disproportionate amount (45%) of delivery costs. Among privately insured patients, uncomplicated cesareans run about $13,000. Meaning that the doctor is going to be making a lot more for a birth that requires a more complicated procedure, but takes less of his or her time. TIME- another factor. Dr. Jane Dimer, a Group Health obstetrician who chairs the regional chapter of the American College of Obstetricians and Gynecologists and co-chairs with Thompson the state’s perinatal advisory committee, commented in the article Taking Away the Incentive for Too Many C-Sections “The incentives for C-section go beyond money. “In nature, labor can go on for hours and is highly unpredictable,” whereas a C-section delivery is highly predictable and far shorter. “In American culture, where time is money, having something that is finite and predictable is highly desirable,” she says.

There is a lot of literature and many studies that support the need for a reduction in our c-section rate. The Office on Women’s Health at the U.S. Department of Health and Human Services has stated “Many experts think as many as half of all C-sections are unnecessary.” The outcome for a cesarean section may not fully be understood my many people. A cesarean section is major abdominal surgery which will require a longer hospital stay and more prolonged healing time than a vaginal birth. With a cesarean birth, the mother has an increased chance of infection around the incision, in the uterus, and in nearby organs as well as an increased chance of injuries to the bladder or bowel. In many hospitals there is a fair amount of time that passes between the baby being born and the mother having direct contact with her child. This lapse in time disrupts the very important bonding time for parents and newborn. There are also downsides for a baby born via c-section. Anesthesia: Some babies are affected by the drugs given to the mother for anesthesia during surgery. These medications make the woman numb so she can’t feel pain. But they may cause the baby to be inactive or sluggish. Breathing problems may occur. Even if they are full-term, babies born by c-section are more likely to have breathing problems than babies who are delivered vaginally. Also, depending on where one lives and the care providers one has access to, it may be difficult to find a practitioner that will deliver a subsequent baby vaginally (VBAC). This may leave the expectant mother with no choice but another c-section.

So here we have many medical and emotional downsides to receiving a c-section. But who would have thought there would a financial negative to this surgery? Recently, insurance companies have been charging a higher premium or even denying coverage to those that have given birth via c-section. The insurance companies know that many doctors are not delivering VBACs (vaginal births after cesarean) and as I mentioned earlier, higher costs, longer hospital stays and more medication are all associated with c-sections. All this equals a higher payout from the insurance company. Not only are women compromising their birth experience, their bodies and their baby’s well being, now they may have to actually pay more for health insurance!

In a June 2008 New York Times article “After Caesareans, Some See Higher Insurance Cost “ Susan Pisano of America’s Health Insurance Plans states, Insurers’ rules on prior Cesareans vary by company and also by state, since the states regulate insurers.” She goes on to say “Some companies ignore the surgery, but others treat it like a pre-existing condition. Sometimes the coverage will come with a rider saying that coverage for a Cesarean delivery is excluded for a period of time. Sometimes applicants with prior Cesareans are charged higher premiums or deductibles.”

This all seems like a catch 22. Insurance companies are paying doctors more to do a cesarean compared to a vaginal birth. Many doctors are jumping to c-sections quicker, practicing defensive medicine from fear of being sued and already shouldering the cost of sky-high malpractice insurance. And then insurance companies turn around and charge the mother, who may not have even wanted the surgery, more money to get health coverage. OY! With C-sections accounting for 45 percent of the $86 billion the U.S. spends on childbirth each year, lowering the C-section rate could go a ways toward paying for President Obama’s goal of getting health coverage to everyone in the country.

What can a mother do to prevent an unnecessary surgery?

Talk to your care provider! If you are not a high-risk patient, don’t work with a doctor that is used to practicing more routine interventions that high-risk patients need. Ask the care provider for his/her c-section rates and induction rates. Who you choose to give birth with will have a big effect on how your birth unfolds.

Get good support! A growing body of research shows that the use of a doula has clear benefits for families during childbirth and postpartum periods, with no known risks. Whether it be a professional labor support doula, or just your partner, friend or mother, have people around you that trust the birth process and your ability to birth!

Stay at home as long as possible If you have chosen to have a doula present at your birth, most likely she will be laboring at home with you. Part of the advantage of that is that she has experience recognizing when you have moved into active labor or have transitioned into the first stage of labor. If you arrive at the hospital too early, you will likely be thrown onto their timetable and possibly given pitocen to speed up your labor. Many hospitals like to see the laboring mom progress 1 cm every one to two hours. This may not be how your labor unfolds, which doesn’t necessarily mean anything is wrong - your body and baby just may not be following Friedman’s curve (a common, still-used approach for determining how labor *should* progress).

Demand less routine interventions Again, if you are not a high-risk patient, you do not need to be treated like a high-risk patient. Ask about intermittent monitoring, freedom of movement, and eating and drinking during labor. Can you have a hep lock instead of a full time IV fluid drip? Instead of jumping right to pitocen to move labor along, can you try alternatives like nipple stimulation, castor oil or an enema?

Avoid unnecessary inductions Schedules (whether it be yours or the doctor’s) are never a good reason to induce. Neither is a presumed “big baby.” Ultrasound predictions have a fairly large margin of error.

Discover pain management techniques Start to explore ways in which you deal with pain, both physically or mentally. Look back on your past and think of times where you were physically challenged, maybe an athletic challenge or illness, and try to remember what helped you through those really tough moments. I am sure any marathoner will tell you that completing 26 miles is just as much of a mental challenge as it is a physical one. Think about relaxation techniques, deep breathing exercises and whether you might like heat, ice, massage or water therapy to aid you during contractions.

Trust your body and your baby! Remind yourself that birth is a natural and normal part of life. In The Business of Being Born, Dr. Jacques Moritz, OB/GYN at St. Luke’s/Roosevelt reminds us: “98% of obstetrics is boring, 2% is exciting.” Why should you jump to the conclusion that something will go wrong and you will be in the 2% he referred to? Trust that your body knows how to birth your baby and that your baby knows how to be born.

Add comment October 22nd, 2009

Breathing for Labor, A Yogic Point of View

I am going to go out on a limb and say: “I strongly believe the best breathing for labor is deep-belly breathing!” There, I said it. This may upset some, or contradict what others believe and what some childbirth educators are teaching. However, from my experience as a labor support doula, this is what I have seen work best. The days of the Lamaze hee-hee-hoo breathing is (thankfully!) falling into the past. Now, I say this with great respect to Lamaze International, being a member and certified Lamaze teacher myself. When I took a certification course 3 years ago, my teacher explained that Lamaze no longer teaches that method.

The reason I like deep-belly breathing is because it helps move the body into the action of the parasympathetic nervous system. The autonomic nervous system (ANS) is divided into two parts: the sympathetic nervous system (the fight-or-flight response), and the parasympathetic nervous system (the rest-and-relax response). The body responds to the parasympathetic nervous system by slowing the heart rate and decreasing blood pressure while increasing the release of endorphins.

I admit that my experience can be considered biased, since my doula clients are also primarily my prenatal yoga students – these women already have a relationship to deep breathing. One reason prenatal vinyasa yoga is so conducive to teaching expectant moms how to connect to the breath is because it encourages them to link breath and movement. This helps to create a mindful connection to the breath; even if they are in a stationary position, they will have a memory of their own relationship to their breath. When the mother is dealing with the growing pain of a contraction, she has the imprinted memory of connecting to her breath and trying to relax her mind and body.

There may be times during labor - the transition period, resisting the urge to push, the pushing stage, or as the baby’s head is crowning - when deep breathing is challenging. The breath may end up short and shallow, blown out, or what I call “defused breath.” However, if the intention is still to try and take a deep breath, even though it may not come to fruition, the mother gains the benefits of it, as opposed to consciously taking shallow breaths that may not be as helpful, and may cause additional tension.

I have found that patterned or coached breathing, which can have a positive effect by creating a helpful distraction, can also cause short, shallow breathing, and potentially hyperventilation, muscle tension, and anxiety. I believe there are more beneficial ways to distract from the sensation of the contraction. Some women like to count their breaths: 4 counts to inhale, 4 counts to exhale, and so forth. This type of breathing is often used in yoga, called sama vritti pranayamaor even-fluctuation breathing . The individual still receives the helpful effects of deep breathing while finding a distraction or focal point within the breath.

Another benefit to the deep-breathing method is figuring out what part of the breath you need to facilitate. By this I mean that you can use the breath differently depending on the task at hand. When faced with a challenging situation where you may need a little more energy, focusing on the inhale can provide you with more energy or prana. This is called the inhalation, (puraka) which stimulates the body. The other side of the breath is the exhalation (rechak), which cools and relaxes the body and mind. Particularly in labor, this may be useful in reminding moms that instead of tightening their body when feeling a lot of sensation, they can use the exhalation to try and surrender to the discomfort. *Please remember that in traditional pranayama there would be a third part to the breathing, the breath retention (kumbhaka), which is not appropriate during pregnancy.

I also teach a variation of viloma breathing, or 3-part breathing, in class. One of the PYC teachers, Michelle, reported that she used this technique while in labor with her daughter. Here, the pranayama is executed by breathing into the belly, then drawing a little more breath into the ribcage, allowing the ribs to widen all the way up to the collarbone. Exhale from the top downward, let the air out from the ribcage, allow the ribs to slide closer together and the belly to deflate, gently drawing the navel towards the spine. The benefits are similar to those of other deep-breathing techniques which, while calming the mind and relaxing the body, slow the heart rate and have a calming effect on the central nervous system. They also oxygenate the blood and purge the lungs of residual carbon dioxide.

Another technique to explore is exhaling with vocalization. hmmm…ahhh…oooh…shhhh Again, this encourages a commitment to a long, deep inhale and long, slow exhale. The benefit of adding a vocalized sound is that the listener can hear the quality of the voice and notice if the throat is constricted or open. (This goes back to my favorite saying: “Open throat, open vagina”!)

However much I believe in the benefits of deep breathing, it is really up to the individual to discover what breathing techniques are most effective at a given moment. You may find yourself jumping between several techniques and discovering usefulness for each at different times of your labor. The most important thing is to commit to your breath and trust that it will help you.

Add comment October 13th, 2009

Dispelling a Myth About the Umbilical Cord

My friend and future midwife, Jocelyn, passed this article on to me. I thought it was a great piece to post on the blog since I often hear women say, “Thank goodness I had a cesarean! The cord was wrapped around the baby’s neck and was choking the baby!” I completely understand why one would think that, however about 1/3 of babies are born with the cord either around the neck or entangled around the baby’s torso. The majority of the time this is completely harmless, the doctor will clamp the cord and cut it as the baby is emerging. Other times, the care provider can actually somersault the baby out and disentangle the baby.

Dr. Stuart J. Fischbein, MD FACOG, BAC wrote a wonderful article going further into details about this phenomenon. Please read and enjoy!

Dispelling a Myth About the Umbilical Cord

The umbilical cord around the fetus’ neck cannot strangle your baby! There, I said it. Now, let’s discuss the logic behind this truth. Nature has devised a system to nourish the developing baby inside the womb of all mammals. The placenta and umbilical cord are an amazing creation of both form and function. The placenta acts as a factory for hormones to support the pregnancy, a filter that among a myriad of tasks acts to bring in good things and remove waste and provides a reserve of blood and oxygen to support the baby through labor. The umbilical cord is the conduit by which nutrients such as sugar and oxygen help feed the baby via its two veins while through its one artery passes the waste by-products of growth.

Understanding how a baby gets its oxygen allows us to understand why a baby cannot strangle or “choke” on its cord. In order to choke, one must be using its trachea to breath air. Clearly, there is no air in the uterus, the baby does not breathe through its throat and, therefore, cannot choke. When an ultrasound reveals the cord around the neck it is a normal human response to anthropormorphasize the intrauterine baby to our extrauterine experience. But this is not the case and there is no reason to have fear. So, let’s dispel once and for all the rumor that a cord around the neck (nuchal cord) is more dangerous than any other situation. About 35-40% of normal term babies are born with the cord around the neck at least once. It can also be wrapped around the body or legs or even at times have a true knot. None of which are usually significant as the cord is designed to deal with this.

Cord compression can occur anytime during pregnancy. The cord is well equipped to handle temporary squeezing as the 3 vessels are cushioned by a matrix called Wharton’s jelly and the surrounding amniotic fluid. In labor, sometimes after the bag of waters breaks and fluid leaks out, the cord can be repeatedly compressed with contractions. This is not uncommon and is not, by itself, a sign of distress. Your practitioner or nurse can listen to or interpret the fetal heart rate pattern to know whether any intervention is necessary. And the compression of the cord almost never is an emergency or a cause for the tragic death of a baby inside the womb. When that tragedy occurs we all want to know why and often, mistakenly, we are told it was a “cord accident”. Compared to the number of times I have heard this mentioned by patients or news stories the real truth is that this is a very rare event.

Please be reassured that your baby will not strangle on its cord because it is not breathing through its neck like you and I. If you hear someone repeat this rumor you would be doing a great service to pregnant women everywhere by logically explaining to them the reasons why.

34 comments October 9th, 2009