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D R A M A_ Q U E E N
- - - - - - - - - - E D I T O R ' S_N O T E Look for excerpts from Anne Lamott's new book, "Traveling Mercies," on Fridays; Word by Word, Lamott's biweekly Thursday column, will return March 4. - - - - - - - - - - T A B L E_T A L K Should women be able to have elective C-sections? Sound off on risk and choice in childbirth in the Mothers area of Table Talk ___________________ Search barnesandnoble.com
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The cruelest cutback?
CAESAREANS ARE ON THE CUTTING EDGE OF CONTROVERSY, BUT POLARIZED DOCTORS, BUREAUCRATS AND FEMINISTS IN THE FRAY HAVEN'T AGREED YET ON THEIR COMMON ENEMY -- HMOS. BY FIONA MORGAN | Most women faced with the sudden decision to have a C-section in the heat of labor have one primary thought: I want this baby out healthy and I want it out now. Only after the birth, with a baby safe in hand, do most women question whether the surgery was actually necessary, or part of a doctor's agenda to reduce liability, or an HMO's cost-cutting strategy. Only when their abdominal muscles have started to patch themselves together again and they can get up off a couch without help do most women have the luxury of time to wonder if they might have had a healthy vaginal birth if they had just pushed for 30 minutes more. This month, four leading birth specialists raised even more questions about C-sections. In an article published in the New England Journal of Medicine, four Boston obstetricians criticized a 1987 Department of Health and Human Services agenda called Healthy People 2000 that suggested reducing the rate of annual Caesarean births to 15 percent of total annual births, down from its current level of 21 percent. The authors of the article warned that the target percentage cited in the agenda, and the proposed methods of achieving that target, are economically motivated and could cause harm to mothers and their babies. The rate of C-section births was at its highest -- approximately 25 percent -- in 1988. "Healthy People 2000," a broad-based health agenda based on input from various public and private health organizations, recommends lowering the national rate by several strategies, including the increase of Vaginal Births after Caesarean (VBACs), which occur when a woman gives birth vaginally after previously having a Caesarean. Drs. Benjamin Sachs and Cindy Kobelin of Beth Israel Deaconess Medical Center and Mary Ames Castro and Fredric Frigoletto of Massachusetts General Hospital, who jointly authored the New England Journal article, wrote that the 15 percent guideline "may have a detrimental effect on maternal and infant health," adding that "there is no evidence supporting this target." In about 1 percent of VBACs, the mother's uterus ruptures at the scar and hemorrhages, and she is faced with an immediate hysterectomy. And if forceps or vacuum extraction is used for delivery, about 5 percent of babies suffer hairline skull fractures, brain bleeding or other complications, vs. 2 percent of these complications in a normal vaginal delivery. Most C-sections are performed in cases of breech births, placenta previa, irregular fetal heart rates and other complications. In general, vaginal delivery involves less risk, carries a lower death rate for mothers and babies and can cost thousands of dollars less than a C-section. But the doctors' article warns that attempting vaginal delivery is actually more risky if the pregnancy is complicated, and that increasing the number of VBACs and operative vaginal births (meaning deliveries with use of forceps or vacuum) would be unsafe. Most importantly, the doctors charge that "economic forces" are behind the 15 percent target. An elective repeat C-section costs about $900 more than a safe vaginal birth in a labor unit at Israel Deaconess Medical Center. But the issue of cost grows more complex if the birth has complications. If a woman attempts to give birth vaginally and fails, later needing a C-section, the cost is estimated at $3,000 more than a normal vaginal delivery. If her uterus ruptures, she'll face another $4,000 in immediate medical costs, plus $2,000 more for her child. Even though that extra cost would affect uninsured parents substantially, the odds of it occurring are low enough to make an increase in VBACs cost effective for a large insurance company. Furthermore, the Boston doctors noticed an alarming trend: Between 1985 and 1995, the number of women who suffered a ruptured uterus and immediately had hysterectomies tripled in Massachusetts. The data wasn't clear, but they suspected that this resulted from pressure to try vaginal labor in cases where, years earlier, doctors and patients would have opted for a C-section delivery. Were doctors exposing pregnant women to unnecessary risks because they felt pressure from insurance companies and government guidelines to reduce an overall rate? So they investigated and found the same trends in other states, such as Pennsylvania and Florida, as well. Government guidelines for public hospitals and health management companies were encouraging vaginal births without special attention to the complications in specific cases or the number of high-risk pregnancies that a physician will take on. N E X T_ P A G E: Financial incentive for a risky reduction in C-sections |
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