Archive for May, 2008

Insult to Injury: C-section Moms Denied Insurance

The New York Times is on a roll this week. One article reports on a study linking the rising cesarean rate to the rise in “late preterm” infants — those born at 34 to 37 weeks, when they are at a higher risk of breathing problems, breastfeeding difficulties, and spending their first days of life separated from their mothers in a Neonatal Intensive Care Unit. Another article blows the whistle on insurance companies denying individual plans to women who’ve previously given birth by cesarean. Treating the first cesarean as a pre-existing condition, the insurers argue such women are at a higher “risk” of having another surgery — which they are, because so many physicians and hospitals are discouraging, or refusing outright, women a vaginal birth after cesarean (VBAC). The Times reports that 500,000 U.S. women anually give birth after previous cesarean, and it has previously reported that at least 300 hospitals have official VBAC bans.

The medical insurers blame physicians and women for a glut of “elective” C-sections, which cost them more; physicians blame women and their own malpractice insurers. “I think there is pressure by patients on physicians to deliver early-ish when someone’s uncomfortable,” said Sarah J. Kilpatrick, head of ACOG’s obstetric practice committee, “and there is medico-legal pressure. Obstetricians are afraid of being sued,” so they may “proceed with a Caesarean to deliver the fetus when the fetus is probably fine.” What Kilpatrick doesn’t say is that the ACOG committee she heads is responsible for the de facto VBAC ban, which plays a huge part in the rising cesarean rate — and, as the study suggests, the rising rate of preterm babies.

The losers in all this, of course, are women and their families: going through unnecessary primary cesareans, then being discouraged or flat out denied normal, physiological birth for their next pregnancy, on top of that being denied health insurance because the repeat cesarean their providers are insisting upon would cost the insurer more money, and having babies at higher risk of being born too early, not to mention the risks of repeated major abdominal surgery for mom. And we call this maternity “care”?

Missouri Families & Midwives Lose

Missouri came tantalizingly close to licensing Certified Professional Midwives last week, with a bill passing the Senate and headed for a sure vote in the House, but was held up because “certain legislators buckled to a well-funded medical lobby,” said one consumer lobbyist. The St. Louis Dispatch reports that the Missouri State Medical Association “strongly opposed the bill over public health concerns,” but the data support the safety of planned, midwife-attended home birth — and history doesn’t support criminalizing healthcare providers.

High Risk for Whom?

The two most common reasons given for a high C-section rate are that a) more women are having “high-risk” pregnancies, and b) more women are obese. This week’s Washington Post story on the link between rising malpractice premiums and rising cesarean rates suggests (like others before it) that it’s not so much women and their health status that are to blame, but their providers and a system that rewards unnecessary intervention. Nearly 1 in 3 American women are going through major surgery to give birth, but only a fraction of them are “high risk” or obese (and the C-section rate has been rising at a much faster clip than the rates of obesity and multiples).

Take a look at Our Bodies, Ourselves‘ take on the purported connection between obesity and cesarean section. While it’s true that obese women are more likely to have a cesarean, it’s not clear that it’s because they need a cesarean. In fact, many of the women labeled “high risk” are labeled so more because a physician is at risk of losing a hypothetical lawsuit, not because supporting a physiological birth would increase the mother’s or baby’s risk of complications. And that’s unethical. “Any physician who picks up a scalpel and does major abdominal surgery…because that doctor is afraid of litigation, is not practicing medicine but is practicing fear and greed,” Marsden Wagner, MD, told the Post.