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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
for books about parenting and the family
R E C E N T L Y A sense of threat Raging hormones Momcat Girly girl Better ead than uck BROWSE THE MOTHERS WHO THINK HOT FLASH ARCHIVES - - - - - - - - - - Mamafesto
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THE CRUELEST CUTBACK? | PAGE 1, 2
"We're 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?
Should women be able to have elective C-sections? Sound off on
risk and
choice in childbirth in the Mothers area of Table
Talk
Great expectations Faced with the cruel suspense of an endangered pregnancy, a novelist found that her greatest comfort came from hearing stories, especially the scary ones.
The good doctor When the insurance company turned loose the bill collectors, one obstetrician settled for the price of gratitude.
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