International Cesarean Awareness Network

Education. Support. Advocacy.

Cesareans 17% more likely at for-profit hospitals

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California Watch, a nonpartisan investigative reporting initiative, has released a study showing that for-profit hospitals in California are performing cesareans at higher rates than non-profits, even in low-risk pregnancies.

A database  compiled from state birthing records revealed that, all factors considered, women are at least 17 percent more likely to have a cesarean section at a for-profit hospital than at one that operates as a non-profit. A surgical birth can bring in twice the revenue of a vaginal delivery.

In addition, some hospitals appear to be performing more C-sections for non-medical reasons – including an individual doctor’s level of patience and the staffing schedules in maternity wards, according to interviews with health professionals…

…California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus – positioned head down – at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, while for-profit hospitals had a rate of 19 percent.

That may seem like a small percentage gap to the casual observer, but medical experts consider it a significant difference. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital. (When calculated without weighting averages by number of patients, the difference is slightly larger.)

This analysis provides evidence of what many have long suspected – that profit drives cesarean rates. As ICAN President Desiree Andrews comments:

“This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate,” said Desirre Andrews, president of the International Cesarean Awareness Network, a nonprofit group that would like to see C-sections only in cases of medical need.

Eugene Declerq weighs in on the study, noting that while profit motives may not be explicit, other factors such as efficiency can result in the same effect:

Gene Declercq, professor of community health sciences at the Boston University School of Public Health, agrees that hospitals would not explicitly push C-sections for profit. But subtle incentives to increase efficiency could have the same effect.

“There are factors that are attractive to hospitals in terms of training and staff and facilities,” he said. “It’s a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need.” Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.

Two ICAN mamas are also quoted in the report, citing their own experiences at California hospitals.

Even at nonprofit hospitals, some women say they felt pressured to have a C-section.

Rebecca Zavala, 29, a teacher and makeup artist in Ventura, was one.

Zavala consented to have her delivery induced a week early because the baby’s head seemed large and because the doctor was about to leave for vacation.

Zavala went to the nonprofit Santa Monica-UCLA Medical Center, where nurses gave her drugs to dilate her cervix and start the contractions. After four hours, in which labor progressed slowly, Zavala’s doctor broke her water and turned up the drug, stimulating contractions.

“It felt like there was this monster on top of me all of a sudden,” Zavala said. “It was terrifying. I was totally unprepared for anything like that.”

Shortly thereafter, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed. Nurses congratulated Zavala on being an accommodating patient.

But Zavala said she felt manipulated. Her doctor hadn’t told her that induction increased the likelihood that she’d have a C-section, and that C-sections came with health risks, she said. Now that she is pregnant again, she has learned that most hospitals are unlikely to allow a woman with a prior C-section to give birth naturally.

“She told me nothing,” Zavala said of her doctor, noting that the doctor left for her vacation shortly after the delivery.

And…

For some, a C-section can have devastating consequences.

After Heather Kirwan had been in labor for a few hours her doctor at Rancho Springs Medical Center in Murrieta urged her to have a C-section, warning that the baby was too big for her birth canal. She reluctantly agreed to the procedure, but now questions that decision.

“She ended up being a 5-pound, 12-ounce baby,” said Kirwan, 26, a manager for The Home Depot who lives in Murrieta. “So that was obviously a lie.”

A year and a half later, Kirwan was pregnant again, but the doctors found that the embryo was developing outside the uterus. Before her C-section, Kirwan said no one had warned her that C-sections increase the risk of this life-threatening condition, called ectopic pregnancy. And if it were listed in her lengthy consent form at the time of her first delivery, Kirwan said, no one bothered to point it out.

The doctors removed the embryo, along with one of Kirwan’s ovaries and fallopian tubes. She has been unable to conceive since.

“I’ve been trying for years and years, and I still can’t get pregnant. It’s very heartbreaking,” Kirwan said. “I just want people to know the risks.”

Newsweek: VBAC Access Makes Medical Sense

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ICAN chapter leaders Allison Denenberg and Barbara Stratton, along with president Desirre Andrews, were featured in a Newsweek article yesterday on VBAC.  The article asks the question:  if the evidence for VBAC safety is so clear, why aren’t doctors supporting it?

VBAC advocates hope that health-care reform, with its emphasis on evidence-based medicine, might help turn the tide on VBACs. The VBAC stigma among doctors and hospitals, based more on fears about multi-million-dollar lawsuits than on data, has forced many women to switch providers, often traveling out of their way to find a supportive OB or midwife and a willing hospital. Since 1996, one third of hospitals and half of physicians no longer allow women to have a VBAC.

Allison shares her primary and repeat cesarean experiences, highlighting that even if a repeat cesarean is the outcome, the opportunity to try for VBAC is crucial.

When she was pregnant with her second child, Allison Denenberg signed on with one of northern Virginia’s VBAC go-to doctors to avoid another C-section. Denenberg didn’t want to have to recover from abdominal surgery while taking care of a toddler and a new baby. She wanted to breastfeed, which can be more challenging after a C-section (positioning a baby to nurse can be uncomfortable and many women find that their milk takes several days to come in). She wanted her baby to pick his or her own birthday. And she wanted a positive birthing experience; after her first C-section, Denenberg worried that she hadn’t pushed effectively and blamed herself.

This time, Denenberg wanted to bond with her baby uninterrupted after birth without a surgical curtain in the way and she wanted to care for her baby “without having to call somebody for help,” she says. A Virginia chapter leader for the International Cesarean Awareness Network (ICAN), an advocacy group that supports VBACs, Denenberg feared that if she didn’t try to deliver her second baby vaginally, she might suffer postpartum depression. In the end—after a 24-hour labor, including three and half hours of pushing—Denenberg underwent a repeat C-section because her baby wasn’t budging. It wasn’t the outcome she wanted, but it was “awesome,” says Denenberg, because she was in control, and her OB cheerleaded her efforts. “It’s a woman’s right,” she says.

Barbara and Desirre are cited on the issue of choice – a woman’s right to make her own informed decisions about childbirth, including VBAC.

Often overlooked is a woman’s fundamental and primal desire to undergo the birthing rite of passage, to have a baby the way babies have been born from the beginning of humankind, complete with the roller coaster of emotional and physical experiences—pain, joy, power, and, ultimately, an overwhelming sense of accomplishment. That desire, and women’s frustration over the lack of support and accessibility, has led ICAN’s Barbara Stratton, based in Baltimore, to organize protest rallies at hospitals with “VBAC bans.” Their signs get right to the point: THANKS, BUT ONCE WAS ENOUGH and CHOOSY MOMS CHOOSE VBAC.

Choice, the ultimate imperative, has been lost for many women. When malpractice insurers refuse to cover VBACs and hospitals fear litigation, doctors can’t offer them and women can’t have them, says Dr. Howard Minkoff, chair of obstetrics and gynecology at Maimonides Medical Center in Brooklyn, N.Y. Now it’s up to ACOG, which sets professional standards, to respond to NIH’s call. What women need are doctors and hospitals that support VBACs, complete information about risks and benefits, and a medical provider who works with them in tandem. “Women are not irrational crazy creatures,” says ICAN president Desirre Andrews. They’re capable of making well-informed decisions for themselves and their babies. Having a VBAC should be one of them.

Be sure to read the full article here.

Insurance Denial for Cesarean Now Illegal

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We’ve blogged before on current insurance companies’ practice of denying individual health insurance coverage to women with previous cesarean surgery. Last October, ICAN mama Peggy Robertson, accompanied by ICAN’s advocacy director Gretchen Humphries, testified on Capitol Hill about her own experience with this discriminatory practice in Colorado.

Whatever your political persuasion, last night’s passage by Congress of health reform legislation ought to bring a smile to your face on at least one count: denying women health insurance due to previous cesarean will be illegal in the United States once the bill is signed into law by President Obama.

An email sent out by the MAMA Campaign this morning also details other benefits of the reform for birthing women and their babies:

  • MAMA Campaign’s “partial victory”: Senator Cantwell’s provision that will have the effect of requiring Medicaid reimbursement for licensed CPMs offering services in licensed birth centers
  • American Association of Birth Center’s provision that mandates Medicaid reimbursement of the birth center facility fee
  • Childbirth Connection’s provision requiring quality assessment and improvement measures specific to maternity care
  • American College of Nurse Midwives’ equitable reimbursement act for Certified Nurse Midwives

Guest Blog: Can healthcare reform decrease unnecessary interventions?

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This guest blog is brought to you by Maureen Finneran Hetrick, ICAN’s Conference Director.

The healthcare bill currently in congress might not survive the current political climate.  But healthcare reform seems to be something most Americans want, in some form or other.  In many ways, the American system of healthcare is to blame for the rise in the cesarean rate and the increased use of interventions.  Anyone who has given birth in the hospital knows how difficult it is have a completely natural birth.  So how could healthcare reform make non-interventive birth easier to obtain?

The maternal mortality rate is rising for the first time in years, and while records across various states are hard to compare due to different data collection, the simultaneous rise in cesareans is likely to have played a part.  The U.S., despite having the most expensive healthcare in the world, ranks low among developed nations in areas like infant mortality.  Critics point to consumer-driven factors like obesity, poor diet, poverty and maternal choice, but can we continue to blame mothers for this?  Or should we reevaluate a system that treats pregnancy and birth as a disease to be cured or even as a profit center?

Atul Gawande’s article in the New Yorker this past summer discussed the healthcare system. He proposed that more expensive healthcare has not been shown to make people healthier.  In fact, some of the most effective institutions that have lower costs than more expensive and interventive systems. In maternity care, studies have shown that home birth, which offers fewer potential interventions than hospital birth, can be as safe as hospital birth.

David Goldhill wrote in the Atlantic Monthly that the current system of healthcare is based on incentivizing procedures.  A doctor who tells a woman over the phone to rest and drink more water will receive less compensation than a doctor who orders additional ultrasounds to evaluate amniotic fluid levels.  And a doctor who performs a cesarean receives more money than a doctor who allows a long labor to end in a spontaneous vaginal birth without intervention.  As an added incentive, the doctor performing the cesarean also has more time to see more patients, bringing in even more money.

No obstetrician will objectively agree that financial concerns impacts the care they provide, but with the costs of additional office staff necessary to navigate the complicated insurance fog, combined with large malpractice insurance premiums, it must be hard to avoid the issue of finances.  Even for those who feel it is not an issue, it may unconsciously affect their care practices.

During birth, so many interventions are part of a hospital’s birth package.  Continuous fetal monitoring “just in case” the baby’s heart rate takes a bad turn. An epidural at 5 cm, “just in case” the anesthesiologist is busy when the mom is in real pain.  A heplock “just in case” she needs IV fluids.  In some cases, these “just in case” standards will be necessary.  But in most cases, these interventions are done for the convenience of the staff, not the health of the mother or baby.  Each intervention not only increases the risk of another intervention, but may have negative side effects of their own.  What would happen if these interventions were not used (nor paid for) and the hospital staff just attended a woman in labor, watching her for signs of a problem?  If a problem arose, only then would the care provider intervene.  Certainly this would reduce the cost consumers paid to hospitals, which probably doesn’t sound very good to those who keep the books at the hospitals.

How can healthcare reform, if it ever happens, affect the overuse of interventions in labor?  Some people have discussed adding a provision to encourage doctors to use evidence-based medicine.  The defensive practices often used by doctors are often not backed by science, particularly the use of continuous fetal monitoring.  Over the almost 40 years since the introduction of the electronic fetal monitor, the fetal death rate has not been reduced by continuous monitoring.  Yet nearly every woman who births in a hospital will be asked to stay tied to a monitor.  The use of continuous monitoring has most certainly increased the cesarean rate, as doctors who see questionable tracings on the machine will usually opt to perform surgery rather than waiting to see how the baby does over the course of labor.  If this policy had been shown to improve the health of babies, it might be worth the additional costs to the mother, but as this is not the case, we must question the overuse of a device that science does not support as effective in preventing deaths.

Healthcare reform could also make it easier for care providers, including Certified Professional Midwives, to attend births at home or in a birth center, where fewer interventions are available. Out of hospital births cost less and would prevent the use of “just in case” interventions.  If medical care was necessary, improved transfer policies could make a potentially dangerous situation safer by having legal status for the care providers who accompany the laboring mother to the hospital.

Current health insurance laws in some states allow women with previous cesareans to be denied health coverage.  Legislation that disallows this type of discrimination would improve access to health coverage for many women, particularly now that 1 in 3 births results in a cesarean.

ICAN does not have a position on the politics of the current healthcare debate.  However, we do support any legislation that increases a woman’s access to care providers of her choice, and birthing locations of her choice.  In addition, we support evidence-based care and encourage women to educate themselves on their choices in birth so as to make informed decisions.

For more information:

International Cesarean Awareness Network (ICAN) – https://ican-online.org/

The Big Push for Midwives – http://www.thebigpushformidwives.org/

American Association of Birth Centers – http://www.birthcenters.org/

Lamaze International – http://www.lamaze.org/

Had a cesarean? No maternity coverage for you in CO

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The Colorado Independent has published an article chronicling one reporter’s quest to find non-employer-based maternity coverage in Colorado.

In advance of a bill in the state legislature that would require Colorado’s insurance companies to cover maternity, The Colorado Independent searched for non-employer-based maternity health insurance. How did it go? It was unbelievably frustrating.

Posing as a 34-year-old woman from the high country whose COBRA coverage was running out, this reporter perused websites and called agents to explore the options.

The results were discouraging all-around, but especially so for women with previous cesarean section. As one example illustrates:

According to state underwriting guidelines, the Rocky Mountain Health Plan maternity rider is also not available to any woman with a previous history of pregnancy complications, which include for example a miscarriage, toxemia, pre-eclampsia, cesarean section, etc.

Not only that:

But, he [the insurance agent] explained, if the pregnancy has any complications (like a cesarean section or any other complication as defined here by the Colorado Division of Insurance), suddenly the primary policy—with its separate deductible—picks up coverage.

When that happens, he said “your maternity benefit is totally null and void. It’s not being used…. It can get messy. And it’s horrible. I’m not going to sugarcoat it.

“So it’s expensive,” said the local agent, “and it could not work for you in the long run. But it’s sometimes better than nothing if you can afford it.”

This report illustrates what many women with a previous cesarean have experienced when searching for health insurance coverage. Just over a month ago, ICAN mother Peggy Robertson testified on Capitol Hill about her insurance denial (also in Colorado) experience. Peggy was declined insurance coverage due to her previous cesarean and was told her application would be accepted only if she agreed to be sterilized.

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