The cruelest cutback?

Caesarean sections are on the cutting edge of medical controversy, but polarized doctors, bureaucrats and feminists in the fray haven't agreed yet on their common enemy -- HMOs.

By Fiona Morgan
January 28, 1999 8:32PM (UTC)
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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

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
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.

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noticing a trend that physicians are being reimbursed less for performing
Caesarean sections," Dr. Kobelin told Salon in a phone interview.
"Physician Caesarean section rates are being published, and insurance
companies are deciding not to allow physicians to be providers for their
company if their rate is above a certain percentage. And when they're
looking at a gross rate, they're not taking into account the physician's
practice, including the number of high-risk pregnancies [that the doctor
takes on]." Currently, the article states, most insurance companies reimburse doctors for C-section and vaginal deliveries at the same rate.

"No one is consciously thinking about the Caesarean section rate,"
Kobelin said. "A physician is thinking about having a healthy mother and
baby. But I think, overall, setting a 15 percent rate sends the wrong
message. Rather than telling physicians to monitor their C-section rate, we
have to look at how we practice medicine as a whole, and how we can reduce the risk, not on an individual basis, but on a mass basis. " (Most medical
professionals agree that the best way to reduce the C-section rate is to
concentrate on reducing the number of women having C-sections for the first time.)

Much has changed since the 1970s, when the C-section rate was at a very low 5 percent. Women are now having children later in life, and often their pregnancies present complications. Fetal monitoring devices have
become much more common, as well as more sensitive, occasionally prompting caution unnecessarily. In addition, it has become more common for pregnant women and their doctors to plan an elective C-section birth rather than risk exposing the child to infection or sticking the parents with added costs. Finally, malpractice suits rose dramatically in the 1980s. Some doctors began to practice "defensive medicine," opting for a C-section at any sign of complication. In the age of advanced medical technology, there is less tolerance for taking risks with childbirth.


But in the 1990s, a few trends have begun to shift the Caesarean rate back
down again: the rising economic power of HMOs, the move toward a government-regulated national health-care system and the less powerful, but still influential, feminist-minded natural birth movement. Peer-review programs, second opinion requirements and an increase in the role of nurse-midwives have also reduced the rate.

Yet feminist attitudes toward C-sections have also changed. Since the
1970s, the feminist call has shifted from natural childbirth to choice,
stressing that women should have autonomy over decisions affecting their
bodies. If a woman wants to have an epidural, feminists now say, she
should have one. And if a woman wants to have another C-section rather
than risk uterine rupture, many would argue that she should make the call. In
fact, this month a London gynecologist wrote in the British Medical Health
Journal that one-third of female obstetricians in the city would recommend a
C-section in the case of a normal birth, rather than expose a woman
to prolonged labor or risk of internal damage to the pelvis, anus and
urethra. "We are at a turning point in obstetric thinking," Dr. Sara
Paterson-Brown wrote, citing advances that make C-sections safer than
ever. Societal attitudes now reflect an "intolerance to risk," she added,
and that if we encourage family planning and prenatal screening, "can we do all this and then refuse a woman the right to a safe mode of delivery?"

The Boston doctors charge that "setting a target rate is an
authoritarian approach to health-care delivery. It implies that women
should have no say in their care." But Damon Thompson, a spokesman for
Health and Human Services, defends the "Healthy People 2000" agenda. "It
would only be an authoritarian approach if it was a mandate, and it's not,"
he told Salon. The stated goals of the program are to increase lifespan,
add preventative services and reduce discrepancies in health care among U.S. citizens. "Cost cutting doesn't figure in anywhere," Thompson added.


So why does the New England Journal article strongly suggest that the
agenda itself and the economic pressures physicians face are linked? The
debate points to a growing concern among doctors that a trend toward a
national health-care system, like those in Canada and the United Kingdom,
would mean a "fee-for-service model," pressing economic efficiency over
long-term holistic care, and would replace solid scientifically researched
health agendas with economically driven ones. Doctors have long feared
that a government-run health-care system in the U.S. would be controlled by
badly designed bureaucratic systems and the powerful insurance lobby.

None of the insurance companies contacted for this article -- Blue
Cross, Aetna US Healthcare, Kaiser Permanente Hospitals and Brown and Toland -- said they had used disciplinary measures with doctors with high C-section rates. Beverly Hayson, a spokeswoman for Kaiser Permanente Hospitals, emphatically denied that Kaiser, which serves 8.6 million clients, interferes with patient-doctor decisions. She called the Caesarean debate "a red
herring." "An increase in C-section rates has for a long time been viewed with skepticism and concern by the medical community. Suddenly now, low
C-section rates are seen as a dangerous thing. After all, a C-section is
major surgery. Reducing that kind of physical intervention in general can
be viewed as positive."

The "Healthy People" consortium is a partnership of 360 public and private
organizations, and Thompson insists it is "the farthest thing from an
insurance scam you'll ever see in your life." When the agenda was compiled
from input from its member groups -- such as the American Medical Association, the American College of Obstetricians and Gynecologists and many state Departments of Health -- the consortium also took more than 10,000 public comments into consideration. Only two insurance organizations are members. "It certainly was not cooked up by a couple of bureaucrats," Thompson said.

The target of 15 percent was based on studies from individual hospitals
that had significantly reduced their C-section rates by instituting
peer-review panels and second opinion requirements. The National Institute
of Health this month began a national study instituting these methods in 13
medical centers across the country.


Dr. Lynette Ament is a specialty director of the Nurse-Midwifery Specialty
at the Yale School of Nursing. She is part of a newly instituted review
committee that looks at all C-sections performed at the hospital. "Our
philosophy is that birth is a natural process and it
involves the input of women," Ament says. "There's a time and a place for interventions,
as long as it's medically necessary." The 15 percent target set by the
government also worries the committee. "The big debate is, who is
that 15 percent and is it a realistic number for the nation?"
Ament says that besides reducing the number of first-time C-sections, another way to reduce the overall rate is not to admit women in early labor to the hospital, thus reducing the risk of intervention.

Nurse-midwives receive training and certification through nursing programs and practice with consulting physicians as backup. The most recent data say that about 5 percent of births in the U.S. were delivered by nurse-midwives. In approximately 12 percent of those births, a physician intervened and a C-section was performed, which makes the national C-section rate for midwives significantly less than the national rate. This is largely attributable to the fact that nurse-midwives screen their clients for risk.

"It also has to do with people's philosophy of care and
the amount of input that women have in their care," Ament said. At the
Midwestern hospital where Ament works, rates for C-sections among nurse
midwives in the early '90s were approximately 5 percent, and the overall hospital rate was 11
percent -- much lower than the national average. "I think some of it is
financially compelled, but I haven't seen in my experience that managed
care companies are mandating vaginal births over Caesarean sections."

Thompson said the agenda's target rates "are in no way ever intended to
be substituted for the discretion of individual physicians." But that
seems to be the way insurance companies are using the number, according to Kobelin and her colleagues. Based on personal experience with HMOs, it isn't hard for many patients and caregivers to imagine how a public health agenda, intended as a suggestion, could be used as a convenient catch-all quota for an industry whose primary goal is profit. In the end, feminists, doctors and the HHS agree on what seems like a reasonable goal -- to reduce unnecessary surgery -- but the (in many ways arbitrary) target rate may be vulnerable to easy manipulation for economic gain.


So after all this debate about risk and cost, what do pregnant women
want? How about a Patients' Bill of Rights?

Fiona Morgan

Fiona Morgan is an associate editor for Salon News.

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