October 22, 2009

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.



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