If you have have discriminated against due to your prior cesarean, our government needs to hear about it!

ICAN needs stories about discriminatory insurance practices based on a previous cesarean.  This can include but is not limited to demands for sterilization, restrictions on how soon you can have another pregnancy and be covered, higher premiums, restrictions on the total amount of benefits they will pay, excessively high deductibles for maternity care.  Even if all you have is your name, state, contact information (email is fine) and a description of the circumstances (with the name of the relevant insurance company(ies) if possible) we can use it.  If you have written documentation, that would be pure gold.  There is interest about this at the highest levels of the Federal Govt. and we will use this to open the discussion on other areas of discrimination (like VBAC bans, lack of transparency, etc)….so please, take a moment and get the information to ICAN.  You can email me at advocacy@ican-online.org or you can snail mail to ICAN of Ann Arbor, PO Box 48, Stockbridge, MI  49285.

Your story could make a difference that would improve the care available for millions of women and their babies.

Below is a press release illustrating ICAN’s latest efforts.

ICAN Mother Provides Testimony on Capitol Hill Discriminatory Insurance Practices Investigated by Senate HELP Committee

REDONDO BEACH, CA, October 15, 2009 – Gretchen Humphries, Advocacy Director for the International Cesarean Awareness Network accompanied Peggy Robertson of Centennial, Colorado to a Senate hearing in the Health, Education, Labor and Pensions (HELP) Committee. Ms. Robertson testified about her experiences with discriminatory insurance practices based on her history of cesarean.

Ms. Robertson was featured in a New York Times article in July 2008 after she was declined insurance due to her previous cesarean. She was informed by the insurance company that her application would be accepted if she agreed to be sterilized.

As of 2007, 31.8% of childbearing women in the United States had a cesarean delivery and the rate continues to increase each year. These increases are due, in part, to the growing number of women who are denied the opportunity to have a vaginal birth after cesarean (VBAC) through similarly discriminatory VBAC bans. “The prospect of rendering a third of women uninsurable is frightening and unconscionable,” said Desirre Andrews, President of ICAN. “Many of these women are being pressured or bullied into first-time and repeat cesareans, and to doubly inflict them by leaving them without health insurance is offensive.” Clearly this type of practice potentially affects a very large number of women now and in the future as the cesarean rate continues to climb and the vaginal birth after cesarean rate continues to decline.

The practice of denying a woman health insurance because of a prior cesarean also indicts the medical community. Many of the cesareans performed today are unnecessary or the by-product of an over-interventive labor management process that is rooted in defensive medicine practices. “It is absolutely wrong to deny coverage to women either because of past cesareans or the risk of future cesareans, but it is also wrong to prop up a system where physicians can overuse surgery that both harms the health of women and babies, and forces insurance companies to take on excessive costs.” said Gretchen Humphries, ICAN’s Advocacy Director.

Cesarean section is associated with double to triple the cost of a normal vaginal birth. Cesarean also imposes the risks of medical complications in the short-term and long-term, which often carry high costs. “Insurance companies, in their actuarial pragmatism, are doing the math and recognizing that moms with a history of cesarean are high-cost beneficiaries and working to weed them out of the pool of people they cover. It’s discriminatory and lawmakers need to address this issue and determine a way to protect mothers, both from the practices of the insurance industry and the non-evidence based care from obstetricians,” said Humphries.

Maternity care is the number one most expensive line-item in the U.S. healthcare bill. From 1996 to 2006, the national cesarean rate rose by 50 percent, setting a new record each year from 2000 onward. The proportion of medically induced labors rose by 135 percent from 1990 to 2005, with strong suggestions that these official induction rates identify only roughly 50 percent of actual inductions. The burden on the health care system is staggering for maternity care as it is today. In 2005, the combined hospital charges for birthing women and newborns totaled $79,277,733,843 and exceeded charges for any other condition. Private insurers paid for 51 percent and Medicaid paid for 42 percent of these stays. “Pregnancy and delivery” was the most expensive condition, followed by “newborn infants” for both payers. Six of the ten most common procedures billed to Medicaid and to private insurers in 2005 were maternity related. Cesarean section was the most common operating room procedure for Medicaid, private payers and all payers combined.

As policymakers focus on healthcare reform and finding ways to improve outcomes while lowering costs, ICAN calls on policymakers to address the needs of pregnant women and make low-cost, optimal-outcome birth easier to access.

Currently: ·

Few women are given the information they need to navigate the pitfalls of the defensive medicine model of care that is rampant ·

Women are routinely coerced or pressured into expensive care that does nothing to improve outcomes, especially through the increasing practice of banning vaginal birth after cesarean (VBAC) ·

Access to low-intervention midwife-attended births are hampered by reimbursement issues, or onerous collaborative agreement requirements for practicing midwives

“The unique beauty of maternity care is that we can simultaneously improve quality and reduce costs,” said Andrews. “But we need to start by treating women fairly and equitably, and intelligently reserve medical technology and interventions for when they are appropriate.”

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are more than 117 ICAN Chapters across North America, Canada , and various international locations which hold educational and support meetings for people interested in cesarean prevention and recovery.

Citation: C. Sakala & M. Corry. Evidence-Based Maternity Care: What It Is and What It Can Achieve. 2008.

First, our definitions of the day from Wikipedia…

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making.^[1] It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).^[2]

EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Informed consent is a legal condition whereby a person can be said to have given consent based upon a clear appreciation and understanding of the facts, implications and future consequences of an action. In order to give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts at the time consent is given.

Scientific consensus is the collective judgment, position, and opinion of the community of scientists in a particular field of study. Consensus implies general agreement, though not necessarily unanimity. Scientific consensus is not by itself a scientific argument, and it is not part of the scientific method.

Scientific evidence is evidence which serves to either support or counter a scientific theory or hypothesis. Such evidence is expected to be empirical and properly documented in accordance with scientific method such as is applicable to the particular field of inquiry.

… and a quick review of ACOG’s Practice Bulletin #54, published in July 2004 and the reason why some American hospitals have banned VBAC, recommends, “a physician [be] immediately available throughout active [VBAC] labor who is capable of monitoring labor and performing an emergency cesarean delivery.”

Back to our interview with Dr. Fischbein:

Don’t hospitals ban VBAC because it is dangerous?

They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

What role does malpractice insurance play in VBAC availability?

The reason that a lot of hospitals ban VBACs anyway [despite meeting ACOG’s “immediately available” recommendation] —and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety. The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Aren’t uterine ruptures the primary reason for repeat cesareans in women with a prior cesarean?

Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture.  They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations.  Far more often, it’s something unrelated to the VBAC that causes an emergency.  And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs?

ACOG’s latest VBAC recommendation was based on consensus opinion, not scientific evidence.  Doesn’t that matter to hospitals when implementing VBAC bans?

Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued.

Does the hospital impact how an OB counsels a woman on VBAC?

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

How to OBs feel about working in hospitals with VBAC/breech bans?

For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

How do VBAC bans impact hospital revenues?

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; [the official reason for VBAC bans] will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

How do VBAC bans impact women seeking VBAC?

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth.

How could tort reform impact VBAC supportive OBs and birthing women?

[With] tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives.

I have incredible software on this website called StatCounter and through that I’m able to see what search engine queries bring people to the site.

I’ve noticed more queries asking if VBAC is illegal.

VBAC is not illegal anywhere in the USA.

It is legal to have a hospital VBAC in all 50 states.

It is legal to have a out-of-hospital VBAC in all 50 states.

If someone has told you that VBAC is illegal, they are either misinformed or are outright lying to you.  Ask them to show you the law.  This is something you should be able to easily look up through a google search.  You won’t find it because it doesn’t exist.

Linda Bennett, a retired midwife, clarifies the issue:

I also think it is important for women to know that OOH (out-of-hospital) VBAC whether home or boat or rv in the parking lot of the hospital or motel or unlicensed birthing center is also legal everywhere.

What may not be “allowed” by state regulation or law varies from state to state but if restrictions are present, it is in the form of restrictions on the license or practice of the practitioner IF she is a midwife (MDs can do what they want, although their peers may give them other headaches for attending an OOH birth).

Birth Centers with a license from their state often have restrictions specified in the law or their regulations (force of law) which mean they could lose their license if…and then VBAC.. breech.. multiples.. may be specified along with other restrictive language decided by their state regulatory board.

And I know what I am speaking about, because the small group of midwives I originally worked with in Santa Cruz took our arrests to California’s State Supreme Court over the licensing issue!

So when you hear the term “it is illegal to VBAC,” it is referring to the fact that it is illegal for a non-doctor to attend homebirths.  The physical act of giving birth in your home is not illegal.  If you are planning a hospital birth, and you don’t make it it the hospital in time and end up giving birth in your bathtub, you did not do anything illegal.

Gretchen Humphries, Advocacy Director, ICAN, explains:

[If] there aren’t laws specifically naming midwives as illegal… it leaves the impression that they aren’t illegal — which isn’t true.  They are illegal because they are practicing Medicine without a license.  They aren’t illegal because they ARE midwives, they are illegal because they AREN’T doctors.  Unless there is legal language making them legal, they aren’t.  Now, fortunately, this is pretty irrelevant in most states, still…..

Some states, like New Jersey, permit midwives to attend homebirths, but not homebirth VBACs (HBACs).

In other states, like California, homebirth and HBAC are legal for midwives to attend though you technically need to use your right of informed refusal to have a HBAC. 

Some states have legislation prohibiting homebirths or birth center births with midwives, and in those states HBAC would also be considered illegal for them to attend. 

Then there are states that permit some midwives, but not others, to attend homebirth.  Iowa and North Carolina permit certified nurse midwives (CNMs) to attend homebirths, but not certified professional midwives (CPMs.)  There is currently a bill providing for licensure of CPMs in Iowa.  Learn more about House Study Bill 229 at Friends of Iowa Midwives.

So why would someone tell you that VBAC is illegal?  Three reasons.  First, it ends the conversation.  One might be apt to debate or look for another care provider if they are told “our hospital doesn’t permit them” or “this OB doesn’t attend them.”  But if you are told it’s illegal, well, most women would just resign themselves to a scheduled repeat cesarean since many women do not want a OOH VBAC.  Linda Bennett gives us the second reason, “It is often convenient ’shorthand’ to speak of ‘illegal’ HBACs but I find this convenience to serve the purposes of the doctors who oppose any OOH births. The HBAC is not illegal.”  Third, to say something is illegal makes it sound really dangerous, risky, and against the common good.  So by continuing the myth that homebirth is illegal, it’s feeding into the “homebirth is for wackos” machine, when it reality, it is perfectly legal for your OB to deliver your baby at home.  What stops them is a mix malpractice insurance pressures, pressure from other doctors, and the real belief that many OB have that birth is a dangerous event.

So, what do you do if you live in an “illegal” state?  There is hope, as Gretchen explains:

In a state where there is no Midwifery Practice Act, you’ll need to depend on your midwives to know what the “climate” for them is like — mine practice openly, advertise widely, go with all their transports, etc. But they ain’t legal.

So, look around.   You may find that you have options you didn’t even know about.

Ready to plan your VBAC?  Start here: I’m pregnant and want a VBAC, what do I do?.

Below is a response written by Stuart J. Fischbein, MD FACOG, Medical Director of the Birth Action Coalition.  OBs like this are few are far between.  If you live in the Los Angeles area and are seeking a vaginal birth, please seek out Dr. Fischbein.  Women of childbearing age need to financially support and reward, yes reward, OBs like this who are willing to out outside the norm and support VBAC.  Go to Dr. Fischbein for your vaginal birth, go to him for your VBAC, shoot, go to him for your annual pap smear.  There are to many OBs out there who don’t care wether you have a vaginal birth or major surgery, who will lead you on only to find some less than honorable reason to perform yet another surgery on you.  Let’s support the OBs who do care, who do support us, and who are willing to write a letter like the one below, sign their name to it, and publicly share it.  Dr. Fischbein is putting his name on the line for us, let’s support him. 

This letter is published with the permission of Dr. Fischbein.

June 23, 2008

Douglas H. Kirkpatrick, MD
The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC  20090-2188

Dear Sir:

I am a practicing OB/ GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth. It is disturbing to me that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients’ rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenet. ACOG’s little “guideline” paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds of hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let’s be honest, due to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.

As to out of hospital birthing, please give me the courtesy of an explanation as to the evidenced-based data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital births under the “obstetric model” of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit. Removing choices from well-informed patients and caring doctors and midwives is wholly un-American.

So please send me detailed information on how ACOG decided outlawing home birth would be a wise thing to do. You must have conclusive scientific data to take such a drastic stand. Please make it available to me so that I may share it with likeminded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with longstanding experience in backing midwives who perform out of hospital births. There must be a clear and concise, non-confidential paper trail you can share with your members. Specific names of committee members who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.

We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. In this case these ramifications have had the undesirable effect of forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery or be coerced into it. Can this be the best we can do for our patients?  Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, which in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option! For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us that no administrator seems to be willing or able to answer. That question is: “If a hospital cannot handle an emergency c/section for VBACs, and most obstetrical emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia not for ruptured uteri, then how can they do obstetrics at all?” For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a “recommendation” that little hospitals unable to afford 24-hour coverage stop providing obstetric services all together? Will this better serve women and their communities throughout America?

I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire. I am baffled that my college thinks this should be a criminal act. Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in out country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us.  I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual. These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicine and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.

I look forward to your response and possibly the beginning of a meaningful dialogue.

Sincerely,

Stuart J. Fischbein, MD FACOG

Medical Advisor, Birth Action Coalition

Dear Friends,
Resolutions were recently introduced by the AMA to support ACOG’s position against home birth and to “develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.”
Please help send a message to the AMA and ACOG, and to our state and federal legislators, to tell them that we object to these resolutions and we view legislation that would restrict a woman’s right to choose a home birth as a being contrary to scientific evidence and a violation of women’s basic human rights.
http://www.ipetitions.com/petition/birthathome/
Thank you.

Imagine having a major complication requiring a life-saving cesarean and then being denied insurance?  How angry would you be?  Without this surgery, you, or your child, would have died and now you are uninsurable.

Imagine having a cesarean for less dire reasons… convenience of your doctor or even a primary elective cesarean, and then being denied health insurance.  How angry would you be? 

I don’t think anyone could imagine being denied insurance after having a surgery like cesarean section that has become so common, so everyday, so familiar, but we are here.

Frightening.

I can’t wait to see how this all plays out.  Read ICAN’s response to this phenomenon here.

After Caesareans, Some See Higher Insurance Cost

By DENISE GRADY

Published: June 1, 2008

When the Golden Rule Insurance Company rejected her application for health coverage last year, Peggy Robertson was mystified.

Elizabeth Bonet of Sunrise, Fla., with her daughters Mia, 6, and Eva, 2, was told she would pay more for insurance because of her Caesareans. “It made me feel very helpless,” she said.

“It made no sense,” said Ms. Robertson, 39, who lives in Centennial, Colo. “I’m in perfect health.”

She was turned down because she had given birth by Caesarean section. Having the operation once increases the odds that it will be performed again, and if she became pregnant and needed another Caesarean, Golden Rule did not want to pay for it. A letter from the company explained that if she had been sterilized after the Caesarean, or if she were over 40 and had given birth two or more years before applying, she might have qualified.

Ms. Robertson had been shopping around for individual health insurance, the kind that people buy on their own. She already had insurance but was looking for a better rate. After being rejected by Golden Rule, she kept her existing coverage.

With individual insurance, unlike the group coverage usually sponsored by employers, insurance companies in many states are free to pick and choose the people and conditions they cover, and base the price on a person’s medical history. Sometimes, a past Caesarean means higher premiums.

Although it is not known how many women are in Ms. Robertson’s situation, the number seems likely to increase, because the pool of people seeking individual health insurance, now about 18 million, has been growing steadily — and so has the Caesarean rate, which is at an all-time high of 31.1 percent. In 2006, more than 1.2 million Caesareans were performed in the United States, and researchers estimate that each year, half a million women giving birth have had previous Caesareans.

“Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Udy, president of the International Caesarean Awareness Network, a group whose mission is to prevent unnecessary Caesareans.

Although many women who have had a Caesarean can safely have a normal birth later, something that Ms. Udy’s group advocates, in recent years many doctors and hospitals have refused to allow such births, because they carry a small risk of a potentially fatal complication, uterine rupture. Now, Ms. Udy says, insurers are adding insult to injury. Not only are women feeling pressure to have Caesareans that they do not want and may not need, but they may also be denied coverage for the surgery.

“You have women just caught in the middle of this huge triangle of hospitals, insurance companies and doctors pointing the finger at each other,” Ms. Udy said.

Insurers’ rules on prior Caesareans vary by company and also by state, since the states regulate insurers, said Susan Pisano of America’s Health Insurance Plans, a trade group. Some companies ignore the surgery, she said, but others treat it like a pre-existing condition.

“Sometimes the coverage will come with a rider saying that coverage for a Caesarean delivery is excluded for a period of time,” Ms. Pisano said. Sometimes, she said, applicants with prior Caesareans are charged higher premiums or deductibles.

“In many respects it works a lot like other situations where someone has a condition that will foreshadow the potential for higher costs going forward,” Ms. Pisano said.

Her group has reported that although most Americans with health insurance, 160 million, have group plans through employers, the number needing individual policies will probably keep rising, because more and more people are becoming self-employed or taking jobs without health benefits.

In a letter to Ms. Robertson, Golden Rule, which sells individual policies in 30 states, said it would insure a woman who had had a Caesarean only if it could exclude paying for another one for three years. But in Colorado, such exclusions are considered discriminatory and are forbidden, so Golden Rule simply rejects women who have had the surgery, unless they have been sterilized or meet the company’s age requirements.

“If you don’t work for someone who has insurance, and you have to get insurance on your own, this is terrifying,” Ms. Robertson said.

A spokeswoman for Golden Rule declined to explain how long it had been excluding Caesareans, how it had decided to do so or how many were affected, saying the information was proprietary. The company, based in Indianapolis, is owned by UnitedHealthcare, which collects more than $50 billion a year in premiums and has 26 million members, most with group coverage.

In Colorado, people denied individual health insurance can obtain it through a state program, Cover Colorado, which insures about 7,200 people. But the premiums are high, 140 percent of standard rates, a spokeswoman said, adding that some women had enrolled specifically because prior Caesareans had disqualified them from private insurance.

Blue Cross Blue Shield of Florida, which has about 300,000 members with individual coverage, used to exclude repeat Caesareans, but recently began to cover them — for a 25 percent increase in premiums for five years. Like Golden Rule, the company exempts women if they have been sterilized.

“After five years, if there is not a complication of pregnancy, another C-section, or if they get their tubes tied and are no longer in that risk situation, that rate-up goes away,” said Randy M. Kammer, the vice president for regulatory affairs and public policy.

The higher rate is based on a Caesarean costing an average of $2,700 more than a vaginal birth (assuming no complications in either type of delivery). Ms. Kammer said Blue Cross Blue Shield could not provide a tally of how many members were paying the higher rates because of Caesareans.

“The aggravating thing is, there are a lot of elective Caesareans, and that adds to costs,” she said.

Elizabeth Bonet, who lives in Sunrise, Fla., learned about the higher rates this year when she applied to Blue Cross Blue Shield of Florida.

“I was very angry, outraged, shocked,” Ms. Bonet said. “It made me feel very helpless. These were not Caesareans I wanted. They were not elective Caesareans. I very much wanted natural births with both babies and was not able to have them, and to have to pay for that for years is outrageous, and I feel it’s discriminatory as well.”

Each state’s Blue Cross Blue Shield plan sets its own policies. In Texas, a spokeswoman said, a prior Caesarean will not affect a woman’s premiums or insurability, as long as she has recovered fully.

A spokeswoman for another major insurer, Wellpoint, said the company’s decisions about prior Caesareans varied case by case, but declined to explain further.

Aetna does not treat a Caesarean itself as a pre-existing condition, but does factor in chronic or recurring problems that might have led to the Caesarean, like diabetes or high blood pressure, a spokeswoman said.

A spokeswoman for another company, Mega Life and Health Insurance, in North Richland Hills, Tex., said: “If the Caesarean section was considered by the physician to be medically necessary for the safety of the mother or child then coverage is issued without conditions. If the procedure was determined to be ‘elective,’ coverage would be offered with a temporary waiver or at a higher premium rate.”

Insurers often accuse women and obstetricians of scheduling unneeded Caesareans for their own convenience — to deliver the baby at a certain time, or to avoid labor. But it is not known how much of the overall increase in Caesareans is because of a rise in unnecessary operations, or how many Caesareans are done at the mother’s request, according to a 2006 report by the National Institutes of Health.

“I think it’s really a very small amount, but we need more data,” said Dr. Mary D’Alton, chief of obstetrics and gynecology at Columbia University Medical Center, and an author of the report.

She said she was amazed to hear that insurers would charge higher premiums or deny coverage because of a past Caesarean.

“I would think if it’s happening, the medical profession has to take a stand,” Dr. D’Alton said.

But to people familiar with the rough and tumble world of individual insurance, the companies’ practices are no surprise.

Individual insurance differs sharply from the group coverage with which most people are familiar. Group policies generally require that the insurer cover everybody in the group, and charge the same rates for all. But with individual coverage, insurers in many states can vary their prices based on medical history, exclude certain services or reject anyone they consider a bad risk. (Several states, however, including New York, New Jersey and Massachusetts, ban such practices.)

Insurers say they need these strategies to protect themselves, because some customers apply only after they get sick or pregnant, skewing the pool toward people with high expenses.

Ms. Robertson said that had she known a Caesarean was grounds for rejection, she would not have even applied to Golden Rule, because the denial may be held against her in the future. Insurers routinely ask applicants if they have ever been denied, and red-flag anyone who says yes.

“My understanding is that once you’re denied it’s hard to get other insurance,” Ms. Robertson said. “Man, is that a scary thing.”

"After years of waiting, South Dakota families now have an option for out of hospital births.  Today, Governor Rounds signed into law a bill that allows South Dakota Certified Nurse Midwives to attend births without a previously required collaborative agreement if they are providing care outside of the hospital. 

South Dakota’s Nurse Midwives praised the Govenor, Legislators and the South Dakota Department of Health Secretary, Doneen Hollingsworth, for fighting for families who desire home birth care with qualified providers.   "It is a huge step in the right direction for low risk families who desire alternatives for their birthing experience" says Sue Rooks, a certified nurse midwife from Oral, SD.  "It is great news."  Rooks is the Chairperson of the South Dakota Chapter of the American College of Nurse Midwives, ACNM, the professional organization that provides the credential for nurse midwives.

In anticipation of Senate Bill 34s passage, one CNM, Jeanne Prentice has been working toward establishing a homebirth practice in the Northern Hills.  Prentice already practices in Wyoming just one mile across the border in Beulah where she provides prenatal care to those in Wyoming who choose out of hospital births but is licensed in South Dakota as well.  Prentice has been unable to provide out of hospital care to South Dakota women because of a law that required her to have a signed agreement with a physician as a pre-requisit to practice.  Senate Bill 34 removes this requirement for nurse midwives who are providing care in "certain circumstances" – homebirths.  
The new law goes into effect on July 1st."

She links to another great website: “The Big Push For Midwives, launched on January 24, is a coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states and the District of Columbia. The website includes a page with links to news articles related to midwifery-related legislative efforts, and a map of states [which I've copied below] where licensure is available or where legislation is pending. Licensure is currently available to CPMs in 22 states.”

There is also a page on The Big Push for Midwives website that lists birth resources for the following states: Alabama, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Michigan, Missouri, Nebraska, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, West Virginia, and Wyoming.  (Might be a good place to look if you want a VBAC and are looking for a VBAC supportive provider.)

The relevance of CPM licensure to VBAC moms?  More legal options.

From Wikipedia:

No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.

In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. Childbirth became very clinical with the mother generally subdued with leather straps and ether. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, South Dakota and Wyoming.^[12] However, Certified Nurse Midwives can legally practice in these areas.

People wishing to have a midwife-assisted home birth in the United States should always research the applicable laws in their home state.

I know homebirth sounds like a radical thing, but I have heard story after story of women who would have never considered a homebirth until they started looking for a VBAC supportive OB only to find none and then felt trapped, out of options, and scared.  And so now these women, who would have been quite happy to birth in a hospital, are hiring midwives, regardless of wether it’s legal in their state, and having a homebirth VBAC rather than face the alternative, an unwanted, unnecessary repeat cesarean in a ‘VBAC ban’ hospital.

I hope this is going to be one of the factors that swings the conventional wisdom back to supporting VBAC because when enough women start birthing at home and that an impact is felt in hospital revenues, hospital administrators and OBs might start paying attention.  Unfortunately, by the time that happens, it might be ‘to late’ for the hospitals.  Enough women would have experienced the joy, peace, privacy, and safety of homebirth to never want a hospital birth again.

For Maryland residents: Just click on this link and look up who your Maryland state delegates are. This bill is before the House so you are only writing to your delegates and not your senators.

For those living outside of Maryland, send your letter to the
Committee Health and Government Operations Committee (HGO)
Room 241, House Office Building, Annapolis, MD 21401-1912
(410-841-3770 Annapolis/Baltimore or 301-858-3770 Washington, D.C.)
Chair: Peter A. Hammen

Then, write them a letter. I have copied mine below. Make it your own
using portions of mine if you want to.

Address them properly and mention HB 1407 in the letter. You can send your letter today and/or copy your letter and fax it or email it to Mairi Rothman, CNM at 240-485-1818 so she can mail a copy of all of the letters out at the recommended strategic moment, about 3-4 days before the hearing of the bill (tentatively scheduled for 3/14).

Thank you!

=======================================================

Email Subject Line: Letter regarding HB 1407

February 21, 2008

The Honorable Put Delegate’s Full Name Here
Lowe House Office Building
Annapolis, MD 21401-1991

Dear Delegate Last Name Here:

This letter is to inform you that for the sake of Maryland women’s health care, you must support House Bill 1407, the Birth Options Preservation Act. This bill opens access for women to care by
Certified Nurse Midwives (CNM). Evidence demonstrates equal to superior care is provided by midwives. Women are consistently more satisfied with the clinical and holistic approach of their midwives.

As a childbirth educator and mother, I have used midwifery care both for well-woman care and in childbirth. I have very safe, happy and healthy pregnancies and childbirth experiences at a birth center. When there was any doubt that my first pregnancy might need medical assistance, I was referred to a perinatologist (high risk OB) for co-management and care. Fortunately, in the end, I did not need medical assistance but was grateful that my midwife referred me for medical monitoring to be on the safe side. CNMs are experts in women’s health care through the childbearing years and beyond. They are professionally bound by the Standards of Practice of the American College of Nurse Midwives. They are ethically and clinically prepared and qualified to collaborate and refer to medical care when appropriate.

The Maryland Board of Nursing in its requirement for physician signature to obtain a license has been a barrier to women’s access to midwives. Please support and pass this bill for the good of Maryland families. Show CNMs the same respect for our profession that the women we care for already demonstrate. Give Maryland women access to the health care that they desire and deserve.

I still remember the day you handed out information asking for my vote on the streets of Hampstead one warm summer day. I hope you will listen to my voice and the voice of others and fight for women’s rights to the best health care which must include midwives and better access to them!

Thank you for your efforts and thank you for listening.

Yours in birth,
Jessica Groves
Hampstead, MD

Bradley Method Childbirth Educator & Birth Doula
Trusting Our Bodies

How does HB 1407 change this? Certified Nurse Midwives (CNMs) must get an obstetrician to sign a form agreeing to essentially be available 24/7 for that midwife in order for that midwife to obtain a license. This is problematic for three reasons: 1) midwives’ careers should not be under the control of an obstetrician with whom they compete for clients! Obstetricians are trained in surgery and high risk pregnancies and should not control the well-woman care and the pregnancy care of a low-risk mother choosing a midwife as her care provider. 2) Some obstetricians really want to support CNMs but hesitate to sign this form because doing so makes them afraid they will be liable
for that midwife’s actions. This is not fair to the obstetrician either! 3) This law is redundant. The Standards of Practice that CNMs must abide by already requires them to have a written plan for consultation, collaboration and referral to medical care when appropriate.

Your presence at the rally gives women a voice and supports the House Bill that will change the current law!

What is the schedule for HB 1407?
Monday, Feb 25 – Rally
March 14 – Committee has hearing on HB 1407
March 17 – House delegates vote on HB 1407

What if I cannot attend the rally? Then, please read the next email coming that tells you how to write a letter to your delegate and send it either snail mail (preferred) or by email. Please copy all letters to Mairi Rothman.

For more info about the rally, see below…

===============================================================

CALLING ALL BIRTH OPTIONS ADVOCATES!
(especially those in Maryland)

We have a bill! The Birth Options Preservation Act is House Bill 1407.

This bill proposes to end the requirement that nurse midwives practicing in Maryland have a written agreement with a doctor. This will go a long way to ensuring greater access to nurse midwives throughout the state! Final language is now available on the web site, directly from
http://mlis.state.md.us/2008rs/billfile/hb1407.htm. That page will also throughout the process have up-to-date public information on the bill.

You have all been asking for some time now: what can we do to help ensure that practices like the Takoma Women’s Health Center and the Maternity Center stop closing? Well, here is something you can do right now: We need to all work together to make sure this bill passes! We have the sponsoring Delegates and their staffs all working hard, lobbying not only their colleagues, but
other interested organizations, and things are looking very positive, but without the VISIBLE and AUDIBLE support of midwives and their clients or would-be clients, legislators have no reason to listen.

LET’S GIVE THEM SOMETHING TO LISTEN TO!
Below are instructions and driving directions for attending a Nurse-Midwives Rally Night on Monday, February 25th, in Annapolis. Yes, it is a long drive for some of us, but the forecast is for sun and mild temperatures, and we urge you to try your very best to get there, to stand and be counted. This bill could make a huge difference for the women of Maryland ! If this law had been in affect 5 years ago, some of the midwifery practices which were forced to close over the past few years might still be open.

Here’s how you can help:

1. Come to the Rally! We will gather for inspirational speeches from legislators, midwives and clients, then go to visit our legislators, armed with talking points and other materials to make our case. We will try to send a midwife with as many groups of consumers as possible. They love hearing from constituents, and will be very welcoming!

2. Bring your family and friends to the rally! Post this announcement on any listserves you are on, put up a notice up at work, post it at your favorite coffee shop, nursery school, pediatricians, etc.

3. Write to your legislators! Whether you attend the rally or not, it is a good idea to write to your legislator and let them know you support HB 1407. Email your letter to your friends and family and encourage them to write to their legislator, too!

4. Volunteer to help the legislative committee! In the next ten days, we will be doing phone calls to members, and to legislators to set up appointments. We can use all the help we can get! Please contact Mairi Breen Rothman to let her know if you will come to the Rally, and how many friends you hope to bring with you. We can help you identify your legislator, so we can make appointments for you to visit your own delegates when you come to Annapolis . (Don’t worry—you’ll go in a group with a packet of information!) If you can’t come, you can still write to your delegate, and we would be happy to give you sample language, so contact Mairi even if you
can’t come! Please call Mairi or Tina with any questions (Mairi 301-674-9976,
Tina 410-937-5824)

Hope to hear from ALL of you in the next couple of days. If we all work together, we CAN make this happen!
Mairi Breen Rothman & Tina Fisher, Legislative Liaisons
American College of Nurse-Midwives , Maryland Chapter
============================================================
Nurse-Midwives Lobby Night in Annapolis
Where: Rally @ the Assembly Room (rm. 114) of the Office of the Comptroller
* Enter at the front door on Calvert Street
* All visitors are required to sign in at the front desk with the
Department of General Services Police. Be prepared to show identification
* Parking information listed below! 
* Rally begins @ 6:00 P.M (Please arrive by 5:45!)
* Please plan on being at the Assembly Room by 5:45 P.M. to begin the rally promptly
* Plan on arriving in the Navy-Marine Corps Memorial Stadium parking lot by 5:00 P.M. in order to arrive by shuttle on time
* Park: Navy-Marine Corps Memorial Stadium, 550 Taylor Avenue, Annapolis, MD 21401

Due to severe parking restraints in the area around the Maryland State Government Complex, we recommend that you park in the Navy-Marine Corps Memorial Stadium visitor’s parking lot. A shuttle service will pick you up in the visitor’s lot and bring you to the Complex, which is only a 2-3 minute ride. Please be prepared to pay a maximum of $5 for parking.

Directions (from Washington, D.C. metro area):
Take the Beltway and merge onto US-50 East towarAnnapolis. Get off at Rowe Boulevard South, exit 24, toward Annapolis. Stay in the far right lane as you exit Route 50 onto Rowe Blvd/Md-70 east. Make a right at the second traffic light onto Taylor Avenue/MD-435. The Navy-Marine Corps Memorial Stadium will be on your right before you turn. After turning onto Taylor Avenue, turn at the second entrance to the stadium lot, posted “visitor’s parking.”

Visitors are required to withdraw a ticket from the parking meter machine at the bus stop. If the machine is broken, do not worry about getting a ticket. Depending on when you leave the lot, you will most likely not be required to pay the parking fee. BE PREPARED TO, THOUGH! Take the shuttle bus to the Department of Legislative Services stop, the last one on the loop (do not hesitate to ask the driver for assistance). When you get off, you will be on College Avenue between the Department of Legislative Services Building and the Lowe House Office Building, adjacent to Bladen Street. Proceed down the left side of Bladen Street until you reach the corner of Bladen and Calvert Street. The Office of the Comptroller will be right in front of you! Enter at the front door.

Contact Information

Mairi Breen Rothman – Legislative Liaison, American College of Nurse Midwives Maryland Chapter (301) 674-9976
Patrick Metz – Legislative Director for Delegate Heather R. Mizeur (301) 858-3493