I see things daily that I want to write about, but never actually have the time between laundry, dishes, meal prep and daydreaming of going to the National Institutes of Health’s upcoming free conference entitled Consensus Development Conference on Vaginal Birth After Cesarean: New Insights.  I’m hoping to use my Southwest credit from the cancelled Controversies in Childbirth conference to make a little trip out to Bethesda.  We shall see.

I’ve been on Facebook a lot, where you can become my friend or a fan of the site, because committing to a small little 420 character blurb fits in quite well as I unload the dishwasher and retrieve my toddler off yet another piece of furniture. 

However, the best way to stay in touch with me and receive updates and coupons for upcoming classes, is to join my mailing list.  I am investigating my options for doing an on-line webinar as well, so stay tuned!

So I’m using this quiet moment, at 3am when my children are asleep and I can write this uninterrupted (oh, the luxury!!), to share something that is really special.

In the last few days, a woman had a VBAC with triplets with the legendary Dr. Tate of Atlanta, Georgia.

According to Doula Momma:

The details are just coming out about this VBAC but apparently the woman had her triplets in a hospital attended by Dr. Tate. I am assuming she went natural, as in unmedicated, as that’s generally the way with a VBAC with Dr. Tate.  From what I am reading so far, the first two babies were head down and the third was footling breech. Here are the babies stats according to the ICAN of Atlanta chapter posting.
3 girls, all vaginal, all Apgar 8/9.

A= 4# 6oz, 18.25in @ 10:24pm, vertex.
B= 6# 4oz, 18.25in @ 10:37pm, vertex.
c= 3# 11oz, 16.5in @ 10:39pm, double footling breech extraction.

All three babies are successfully breastfeeding as well.

In a time where VBAC is banned in 50% of US hospitals, either through formal or defacto bans, (ICAN 2009 Hospital Survey) and women of multiples believe that they have no other option but a surgical delivery for their children, this is a huge victory.  There are practitioners that support VBAC.  Maybe even one that lives close to you.  Learn more on finding a provider and your options for planning a VBAC here: I’m pregnant and want a VBAC, what do I do?

Over the years, I have heard the statement:

You are more likely to be struck by lightning or bitten by a shark than experience uterine rupture!

Now, I know I’m ruining the surprise, but this is false.  Today I’m going to get the statistics and run the numbers so you can see for yourself how truly ridiculous this claim is.

Uterine Rupture

For this exercise, we will use the uterine rupture (UR) rate based on one prior low transverse (bikini) cut cesarean in a spontaneous labor determined by Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery (Landon 2004):

Risk of uterine rupture: 1/240 or 0.4%
Risk of brain damaged or dead baby: 1/2000 or 0.05%

Lightning Strikes

Using the faulty theory I’m going to calculate the number of Floridians, since it is the “lightning strike state,” who would be struck by lightning.

Let’s assume that the risk of getting struck by lightning in Florida is the same as uterine rupture (even though the saying goes the risk is greater): 1 in 240 or 0.4% or 0.00416

With 18,328,340 people living in Florida, that would mean that 76,368 people are struck by lightning every year in Florida.  According to the CDC, that is more than the number of Americans who die annually from diabetes (72,449), Alzheimer’s disease (72,432), and influenza and pneumonia (56,326).  Using the National Weather Service stat that 10% of people struck by lightning die, we would have 7,636 people dying in Florida every year from lightning strikes. At that rate, you would have 209 people struck by lightning and 20 of those people dying every day in the state of Florida.

Now, I don’t live in Florida and I’m not an expert in lightning strikes, but that sounds like a lot of people dying.

Now let’s switch our assumptions and use the National Weather Service’s stats.

Odds of being struck by lightning in a given year (reported deaths + injuries)       1/700,000
Odds of being struck by lightning in a given year (estimated total deaths + injuries)      1/400,000

When we turn that fraction into a percentage, we get the following risk of being struck by lightening: 0.00025% – 0.00014%.

Let me ask you, which is bigger?  0.4% or 0.00025%?  (For those who are math-disabled, I’ll give you the answer: 0.4%.)

Using the National Weather Service’s statistics, we get 26 – 46 annual lightning strike related deaths or injuries in Florida.

Which sounds more reasonable to you?  26-46 Floridians struck annually by lightning or 76,368?

And that is assuming that the rate is the SAME as uterine rupture, but the rumor is that the rate of lightning strikes is HIGHER which means MORE than 76,368 Floridians are struck by lightning every year and more than 20 Floridians are dying daily from lightning strikes.

Now, does that pass the smell test?  Does it seem reasonable in the least?  It doesn’t to me.

Some would argue that in order to make the comparison, we need to eliminate the number of non-birthing people in Florida, but you really don’t because the lightning strike doesn’t know whether you are a man, woman, child, or menopausal.  A Floridian women with one prior cesarean in spontaneous labor has the same risk as everyone else to be struck by lightning: 0.00025% – 0.00014%.

Shark Bites

From the Florida Museum of Natural History:

What are the chances of being attacked by a shark?

The chances of being attacked by a shark are very small compared to other animal attacks, natural disasters, and ocean-side dangers. Many more people drown in the ocean every year than are bitten by sharks. The few attacks that occur every year are an excellent indication that sharks do not feed on humans and that most attacks are simply due to mistaken identity. For more information on the relative risk of shark attacks to humans click HERE.

How many people are attacked each year by sharks?

Worldwide there is an average of 50-70 shark attacks every year. The number of attacks has been increasing over the decades as a result of increased human populations and the use of the oceans for recreational activity. As long as humans continue to enter the sharks’ environment, there will be shark attacks. For more information on shark attack statistics click HERE.

We have about 6.5 billion people on the world and 50-70 get bit by a shark annually which works out to 0.00000077% – 0.00000108%.

Again, I ask you, which is greater?  0.00000077% or 0.4%?  (It’s 0.4%.)

But this whole discussion is moot because it’s poor statistics to even compare these events (UR & lightning strikes or shark bites) because they are totally different types of occurrences.

The Actual Figures

This is a great chart from the Floria Museum of Natural History website entitled “A Comparison of Unprovoked Shark Attacks with the Number of Lightning Fatalities in Coastal United States: 1959-2008” where they show even in the state of Florida, over the past 49 years, there have been a mere 453 lightning fatalities and 585 shark bites.  Remember that over 7,600 Floridans would be dying annually if the rate of uterine rupture was the same as the rate of lightning strikes.

Comparing Risks

There are some major problems when one is trying to compare risks of differing events.

One problem is when one uses a lifetime risk statistic as a means for comparison.  You simply cannot take a statistic, like your lifetime risk of being struck by lightning (1 in 5000 which is significantly lower than one’s annual risk,) and compare that to your one-time risk of uterine rupture.  If anything, using the annual risk of lightning strikes would be more accurate, but it still would be a false comparison.

An article by Andrew Pleasant entitled, Communicating statistics and risk, elaborates:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

The second major problem is often the two things you are comparing are so different that the comparison is worthless.  Again, I defer to Mr. Pleasant:

Try not to compare unlike risks. For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different. When people assess risks and make decisions, they usually consider how much control they have over the risk. Driving is a voluntary risk that people feel (correctly or not) that they can control. This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate. The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Going Forward

It can be hard when wading through the (mis)information available on the internet about VBAC, but here are some tips to help you out.

1. Always find the source – If you find some great statistic, but there is no source referenced, be wary.

2. Verify the statistic – If there is a source listed, read through it.  If there is no source listed, do a quick Google search.  It didn’t take me long at all to find all the statistics in this article and run the math.

3. Leave a comment – If you find something on the internet that doesn’t pass the smell test, leave a comment on the blog or email the author asking for the source.

4. Be careful about forwarding things – There is so much misinformation on the internet, so do your friends a favor and don’t forward them emails or articles unless you have verified the information to be true.  That is one way to quickly nip falsehoods in the bud!

For further reading on using statistics, check out, Correlation and Causation:Misuse and Misconception of Statistical Facts and Risk Communication, Risk Statistics, and Risk Comparisons: A Manual for Plant Managers

“Women choose to give birth in hospitals because they believe it is “safer” than birth outside the hospital. ” Birth in the hospital is safer. The only people who appear to be unaware of this are homebirth advocates. All the existing scientific evidence and the existing state and national data show that homebirth has an increased rate of neonatal death compared to hospital birth for comparable risk women. Sure, there are papers that claim to show that homebirth is as safe as hospital birth, but they do that by comparing low risk homebirth to high risk hospital birth, or low risk homebirth to hospital birth in decades past. The Johnson and Daviss BMJ 2005 study ACTUALLY shows that homebirth with a CPM in 2000 had a neonatal death rate almost triple that of hospital birth in 2000. According to the Linked Birth Infant Death 2003-2004 dataset recently released by the CDC, the most dangerous form of PLANNED homebirth in the US is homebirth with a DEM.

Dr. Amy has been debating homebirth on the internet for a while now so many people have had the opportunity to rebut her information.

On July 22, 2008, Anna Clark wrote a piece entitled Who’s Catching Your Baby? on RH Reality Check.  Many people, including Dr. Amy, commented and a really wonderful, but extensive, debate commenced.  A variety of people participated including an attorney with her Masters in Public Health, a MD, midwives of all backgrounds, and the Legislative Chair of the North Carolina Friends of Midwives.

The posts below demonstrate how the major arguments of her anti-homebirth campaign are just not true:

1. her understanding and representation of DEM/CPM midwifery education;
2. her interpretations and representations of neonatal mortality rates (and how the Amish population affects those rates) and;
3. her interpretations and representations of the home vs hospital neonatal mortality rate data of the Johnson and Daviss BMJ 2005 study.

Since there are 56 comments on that piece, and not many people are willing to wade through all that, I’ve picked out the most interesting thirteen and have included them below.  It really is worth reading them all.  You be the judge.

Dr. Amy was the first to comment on the article.

************************************************************

The issue is safety

Homebirth advocates would like women to think that the issue is “choice” and that the AMA is attempting to “outlaw” homebirth. Neither of those things is true.

Why are homebirth advocates lying about this? As usual, it’s because the lie is so much better than the truth. Here’s what the AMA actually said:

1. Homebirth is not as safe as birth in a hospital or licensed birth center.

2. Midwives should be licensed to the standards of the American College of Nurse Midwives.

If homebirth advocates attacked the resolutions on what they actually said, they’d be forced into a discussion they would lose. Homebirth is NOT as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased risk of neonatal death. The Johnson and Daviss BMJ 2005 study that claims to show homebirth is as safe as hospital birth ACTUALLY shows that homebirth has almost TRIPLE the neonatal death rate as hospital birth in the same year. The ACNM standards for midwives ARE the appropriate standards. They are consistent with midwifery standards in EVERY other country in the industrialized world.

Homebirth advocates like to imply that homebirth midwives (direct entry midwives) are just like certified nurse midwives or just like European midwives. That’s not true, either. Homebirth midwives are a second, inferior class of midwives with far less education and training than ANY midwives in the industrialized world. American homebirth midwives would not be eligible for licensure anywhere else.

Homebirth advocates also neglect to mention that the Midwives Alliance of North America (MANA), the trade organization for direct entry midwives, has been collecting detailed safety statistics on homebirths since 2001. They have publicly offered those statistics to organizations that can prove they will used them for the “advancement of midwifery”. Even then anyone who is allowed to view the statistics must sign a legal non-disclosure agreement preventing them from disclosing any data to anyone else. It does not take a rocket scientist to surmise that MANA is almost certainly hiding the fact that their OWN data shows homebirth with a direct entry midwife to be unsafe.

The AMA opposes homebirth on safety grounds, and it opposes homebirth midwives because they don’t meet the world-wide standard for midwives. These are the real issues, the ones that homebirth advocates are trying to hide.

Submitted by Amy Tuteur, MD on July 21, 2008 – 8:38pm.

The Debate is Irrelevant

As it turns out, Amy, we are just weary of torturing the numbers with you. It was fun in 2006, but now it is mostly just tiresome (like the never ending repair of graffiti). You embrace Pang’s conclusion and flawed retrospective methods. We embrace the indifference in neonatal outcomes illustrated in Johnson & Daviss, but recognize that birth is not without risk. You exercise the Wonder Site without considering congenital anomalies and declare victory. We screen for congenital anomalies to assess the relative safety of the setting and the care provider and show equivalence in neonatal outcomes (see the query below). You declare women who extol their home birthing experiences as selfish competitive mommies. We weep for the mothers who birth alone because they do not have access to care. You celebrate the terrific obstetrical process capability we have today with C/S. We applaud the capability, but recognize that some mothers do not survive it and that some families lose their ability to create children because of it and consider that in the analysis of safety in light of the current C/S rate of 31%. Your advice to women concerned about the birthing process is to go find a concierge obstetrician who will nurture them like a midwife. We fight to assure that women who choose to birth at home have access to care.

The rhetoric is getting old, Amy. Compelling women to birth in hospital will not solve our problems. Addressing maternal health and access to care should be our focus (one element of this is the onerous environment in which obstetrics is practiced). Instead, we will all just dance this dance until women who choose to birth at home have access to care (because that is where we will land).

Russ

CDC Wonder Site results for white women, 37+ wks gestation, 20-45 yrs old, singleton, with congenital anomalies removed. Analysis basis inputs provided.

Notes Deaths Births Death
Rate
Certified Nurse Midwife 59 268602 0.22
Doctor of Medicine 1013 3117333 0.32
Doctor of Osteopathy 57 189133 0.30
Other 21 19143 1.10
Other Midwife 8 25702 Suppressed (0.31)
Unknown or not stated 4 9292 Suppressed
—
Dataset: Linked Birth / Infant Death Records, 2003-2004
Query Parameters:
Title:
Age of Infant at Death: Under 1 hour, 1 – 23 hours, 1 – 6 days, 7 – 27 days
Age of Mother: 20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years
Birthplace: All
Birth Weight: 2500 – 2999 grams, 3000 – 3499 grams, 3500 – 3999 grams, 4000 – 4499 grams, 4500 – 4999 grams, 5000 – 8165 grams
Delivery Method: All
Education: All
Gender: All
Gestational Age at Birth: 37 – 39 weeks, 40 weeks, 41 weeks, 42 weeks or more
Hispanic Origin: Non-Hispanic White
ICD-10 130 Groups: All
ICD-10 Codes: A00-B99 (Certain infectious and parasitic diseases), C00-D48 (Neoplasms), D50-D89 (Diseases of the blood and
blood-forming organs and certain disorders involving the immune mechanism), E00-E88 (Endocrine, nutritional and metabolic
diseases), F01-F99 (Mental and behavioural disorders), G00-G98 (Diseases of the nervous system), H00-H57 (Diseases of the eye
and adnexa), H60-H93 (Diseases of the ear and mastoid process), I00-I99 (Diseases of the circulatory system), J00-J98 (Diseases
of the respiratory system), K00-K92 (Diseases of the digestive system), L00-L98 (Diseases of the skin and subcutaneous tissue),
M00-M99 (Diseases of the musculoskeletal system and connective tissue), N00-N98 (Diseases of the genitourinary system), O00-O99
(Pregnancy, childbirth and the puerperium), P00-P96 (Certain conditions originating in the perinatal period), R00-R99 (Symptoms,
signs and abnormal clinical and laboratory findings, not elsewhere classified), U00-U99 (Codes for special purposes)
Live Birth Order: All
Marital Status: All
Medical Attendant: All
Month Prenatal Care Began: All
Plurality or Multiple Birth: Single
Race: White
Regions: All
States: All
Year of Death: All
Group By: Medical Attendant
Show Totals: True
Show Zero Values: True
Calculate Rates Per: 1,000

Submitted by Russ Fawcett on July 23, 2008 – 11:22pm.

Irony

The ultimate irony of the campaign to promote homebirth and license direct entry midwives will be to bring about the demise of direct entry midwifery.

Direct entry midwives and their supporters have successfully tried to confuse American women on two critical points:

1. Homebirth is KNOWN to increase the neonatal death rate
2. American DEMs are grossly undereducated and undertrained compared to ANY other midwives in the industrialized world.

The effort to license DEMs has already let to the national government’s collecting statistics on homebirth with a DEM. The first large data set already shows that homebirth with a DEM triples the rate of neonatal death compared to low risk hospital birth. This is consistent with all the existing scientific evidence on homebirth. Homebirth advocates will no longer be able to pretend to themselves or others that homebirth is safe.

MANA, the trade union for DEMs, has been successful up until now at confusing people about the education and training of DEMs. They created their own certification (”CPM”) which is so close to CNM (certified nurse midwife) as to create confusion. Homebirth advocates routinely cite the practice of midwifery in European countries like the Netherlands, without bothering to explain the American DEMs are nothing like Dutch midwives and would never be considered qualified in the Netherlands. Dutch midwives, like ALL other midwives in the industrialized world are hospital trained with extensive experience in managing complications. In contrast American DEMs never have any hospital training and receive degrees from correspondence courses.

MANA, the DEM trade organization, may continue to withhold the 7 years of safety statistics it has collected, but soon it won’t matter. The government is now involved and the truth can no longer be suppressed.

Here is an interesting fact to ponder:

Suppose that homebirth with a DEM were to increase from less than 1% of births (currently) to 10% of births. All the existing scientific evidence shows that homebirth with a DEM has an excess neonatal mortality rate in the range of 1-2/1000. That would mean 400,000 homebirths would lead to and excess 400-800 neonatal deaths per year. If homebirth with a DEM were to account for only 10% of American births, homebirth would become one of the leading cause of death of term babies in the US.

Submitted by Amy Tuteur, MD on July 24, 2008 – 6:40pm.

Great Zinger, Amy!

Well done.

Once again, however, I need to point out that your conceptual understanding related to the importance of licensing is flawed and your analytical projection is, well, just plain wrong.

On the subject of licensing, you need to understand that it serves a number of purposes. First of all, it promotes access. This is probably the element that most bothers you and your colleagues. I recognize that ACOG’s objective is to force women into the hospital by denying them access to care. This strategy is partially successful in that some women who do not have access to home birth midwifery care do settle for the hospital; however, some women birth at home unattended in the absence of midwifery care, and any excess bad outcomes associated with unassisted birth due to lack of access should be assigned to ACOG. Secondly, licensing allows the consumers to differentiate between credentialed and non-credentialed care providers. Thirdly, it provides a mechanism to assure the standards of care are maintained. In light of your long standing heartburn with the CPM’s training being largely in a clinical setting, I would think you would embrace the regulatory aspects of licensing. Also, it is a first step toward collecting state specific data. Whether you like home birth or not, and whether you like CPMs or not, everyone should support licensing as 1) women will choose to birth at home and they deserve access to care and 2) the CPM is the care provider that attends them. Also, Direct Entry Midwives have been licensed in the US since the late ‘70s and while some regulatory environments are better than others, it is generally considered beneficial. The only one that doesn’t really work at all is Delaware which requires a physician’s signature to obtain a license and ya guys won’t do it, so there is only 1 licensed midwife in the state. Without question, the midwives must be licensed for autonomous practice. One other thing to keep in mind is that contemporary licensing statutes tend to include provisions to protect any other care provider from any liability due to negligence on part of the midwife (even though this is largely for peace of mind for the obstetricians and hospitals as bad outcomes are rare and law suits are even more rare). To my knowledge, these provisions have not been exercised. In summary, licensing is the right answer from every perspective unless your objective is to deny women informed consent and sovereignty over their birthing decisions and constrain them to the hospital.

With regard to your projections of a world in which 10% of births are planned home births with a CPM, we need to make a number of corrections. To begin with, it has already been demonstrated that your claims of 1-2 excess bad outcomes per 1000 births are incorrect. When the CDC Wonder Site data is screened for congenital anomalies, the neonatal mortality rate is indistinguishable for healthy women experiencing normal pregnancies. This is consistent with Johnson and Daviss’ findings. Furthermore, this terrific performance is in an environment in which there is very little infrastructure supporting planned home birth. Clearly claiming an excess mortality rate as high as 2/1000 is a gross exaggeration as the aggregate neonatal mortality rate in the CPM2000 study was 1.7/1000. To illustrate the flaws in your projection designed to scare and bully women into the hospital, let’s for talking purposes analyze an excess rate of 1/1000 in an evaluation of overall safety in the state of North Carolina. I prefer analyzing NC as I have a statewide evaluation of outcomes using the Perinatal Period of Risk Methodology.

To begin with, we have about 120,000 births per year in NC. Our overall perinatal mortality rate is about 12.5/1000 (http://209.217.72.34/VitalStats/TableViewer/tableView.aspx ). For anyone who is not familiar with the perinatal mortality rate, it is the number of deaths in the fetal period (from 20 weeks gestation, depending on convention) plus the intrapartum period (from the onset of labor until birth) and the neonatal period (from birth to 28 days post-partum). In NC we lose about 1500 babies a year. Applying Amy’s little experiment to NC, if 10% of women chose to birth at home with a CPM, that would translate into about 12000 planned home births per year. Using Amy’s (baseless, exaggerated and politically charged) value for excess bad outcomes of 1/1000, we would expect 12 preventable bad outcomes per year (out of 1500 total) due to the planned place of birth (we lose over a thousand lives every year to traffic accidents in NC). It is obvious that this hypothetical large home birth population would not significantly impact our overall perinatal mortality rate even with your inflated values. This simplistic view, however, is grossly inadequate to perform safety analysis.

Now let’s examine the sources of our excess bad outcomes during the perinatal period. The Perinatal Period of Risk Methodology is an analytical tool to assess outcomes in order to aid leaders in health policy on what actions to take. Premature, low birth weight babies (from 500-1500 grams) that do not survive after 24 weeks gestation are placed in the Maternal Health category. In NC, when the overall mortality rate is compared to a low risk group in this category, it is concluded that there are over 200 excess bad outcomes per year due to poor maternal health. We don’t really know how much of this hypothetical home birth group representing 10% of births in NC would be at risk for poor maternal health, but given we are performing a thought experiment, let’s assume it is representative of the overall population. So there is an opportunity to prevent 20 bad outcomes due to poor maternal health. We know that midwifery care is much more effective at promoting health than obstetric care. Let’s assume a 50% improvement resulting in the prevention of 10 bad outcomes due to poor maternal health. The overall perinatal mortality rate is now indistinguishable due to better maternal health offsetting Amy’s (baseless, exaggerated and politically charged) rate of excess bad outcomes of 1/1000.

Now let’s turn our attention to the mother. In the home birth group, we would expect a 4% C/S rate (480 total out of 12000 births). Had those women planned to birth in hospital, their C/S rate would have been 20% (2400). We know there is an excess rate of maternal deaths and hysterectomies due to C/S. Focusing first on hysterectomies (lost opportunity dead babies), rates of hysterectomy are approximately 0.03/1000 for vaginal birth, 0.6/1000 for the first C/S, 0.8/1000 for the second C/S and 5/1000 for subsequent sections. So, approximately 2000 sections are eliminated preventing the loss of fertility for 1-3 women every year. As an aside, one of the fastest growing segments of the home birth community are women who have endured C/S in the past and don’t trust that their birthing decisions will be respected in the hospital. As for maternal deaths, we know the rate of maternal deaths are under reported. In NC, the maternal mortality rate has been reported as 0.12/1000 during the 10 year period from 1987-1996. In addition to being underreported, it is likely higher today in light of the current C/S rate. We know that women undergoing C/S are 2 to 4 times more likely to die in childbirth than women who birth vaginally, so let’s say that the maternal mortality rate is reduced by 50% due to the reduced C/S rate and better maternal health. This hypothetical large home birth group in NC would then save one mother every other year or so. As we all know, the Golden Rule of Obstetrics is that the mother always comes first, so this is a significant difference.

There are myriad other defects in the bucket of morbidity associated with interventions and hospital birth (e.g. episiotomy, birth injury due to forceps and vacuum extraction, infections, etc…). Let’s not forget, also, that millions of dollars would be saved every year which will further improve the lives of the families of North Carolina.

So, what’s the conclusion in this Friday evening comprehensive analysis of safety in a North Carolina in which 10% of women choose to birth at home with an artificially high assumption on neonatal mortality? Well, it would be a terrific North Carolina that steadfastly supports and defends our mothers and families. In reality, as neonatal outcomes for planned home birth are indifferent to hospital for healthy women experiencing normal pregnancies, we would actually have better outcomes due to better maternal health, higher quality of care and reduced cost in this wonderful North Carolina in which 10% of women birthed at home and attended by trained, credentialed and licensed midwives.

Clearly, the key intervention to protect our children is to not let them drive a car!!!! Here’s wishing you a terrific weekend, Amy.

Russ

Submitted by Russ Fawcett on July 25, 2008 – 10:30pm.

Dr Amy, You are incorrect

Dr Amy,
You are incorrect about ALL DEM training in the US. In Florida where DEM’s are Licensed Midwives they are required to attend a 3 year accredited program along with an extensive clinical component that requires attendance at 75 births, most CNM’s are only required to attend 25 births.

In addition to the 75 births, 50 of which must be primary management by the student midwife under direct supervision of either a Licensed Midwife, CNM, or OB, she must also perform at least 50 prenatal, postpartum, and newborn examinations. At least 4 of these must include continuity of care, meaning that the student provides prenatal, birth, postpartum, and newborn care to the same woman.

I did recieve an Associates in Science degree in Midwifery, which I am aware is NOT the same as the CNM required bachelors degree, but you cannot say that DEM’s do NOT have college degrees, my credits ARE transferable!

I had extensive education & training in the management of prevention of complications in addition to the diagnosis & management of complications. I am a specialist of NORMAL BIRTH, I had 3 years of clinical internship, and am highly capable of recognizing when a mom & baby need to be in the hospital and when transfer needs to happen. My hospital transfer rate is 10%, 99.9% of my transfers are non-emergency transfers, with a c/s rate of 6%, and NO neonatal deaths in over 300 births.

The State of Florida tracks statistics for it’s Licensed Midwives and as a state we have excellent outcomes!

2005 was the most recent posted data on the State of Florida Department of Health Council of Licensed Midifery website:

With 38 practicing Licensed Midwives (DEM’s)
18 provide homebirth, 20 work in birth centers
1069 women gave birth, 234 gave birth at home, 571 gave birth in a birth center, the others were transfered to the hospital.

138 women were transfered during pregnancy, 126 transfered during labor: of those, 264 gave birth vaginally, 3% of antepartum transfer had c/s, 6% of labor tranfers had c/s resulting in 99 c/s equaling an 8.5% c/s for women under the care of a Licensed Midwife.

7 women were transfered for postpartum complications, 11 babies were transfered after birth.
There were no maternal deaths, no infant deaths, only 1 fetal death at 29 weeks of pregnancy that was delivered at the hospital.

Timely Prenatal Care
with LM 96.86%
with all other Providers 95.3%

Adequate prenatal care
LM 74.35%
with all other Providers 76.12%

Births over 37 weeks
LM’s 95.29%
All other providers: 83.44%

Normal birth weight
(>2500 g)
LM 98.88%
All other providers 89.64%

Infants that Receive Healthy Start Screening
LM’s 50.15%
All other providers 26.99%

I think you are doing exactly what you are accusing other people of doing Amy, making blanket statements about something in which you do NOT have all the FACTS!

Licensed Midwife, CPM, DEM in Florida

Submitted by Anonymous on July 24, 2008 – 1:13pm.

Thanks for the statistics lesson Dr. Tueter!

I am confused how is 0.61 deaths per 1000 births TRIPLE 1.15 deaths per 1000 births. Moreover, by my calculations these rates are not statistically different.

If you say that women should have unbiased statistics when contemplating a home birth, then you should present them in an unbiased, truthful manner.

More than that, let the statistics stand for themselves and respect women’s ability to make educated and informed choices. Women don’t want to die in childbirth or have their neonate die anymore than you do!

Women are more than capable of making their own choice about birth, weighing the risks and benefits. Many women desire home birth because they don’t want to expose themselves to the many unnecessary interventions that occur once checked into the hospital.

Why is it that my many very educated friends have made comments like:

“I waiting until the last minute to go to the hospital.”

“The more I read [about childbirth in the US] the more I realize how useless my Ob is and how little I want to do with the medical establishment.”

Then there is my friend with cerebral palsy who had natural childbirth about 5 years ago. All her doctor wanted to do was strap her to a bed when she was admitted in labor, although there were no signs of fetal distress or abnormal labor. Instead she had to push against those orders so that she could continue walking during her contractions as we her wish. The result was an uncomplicated, undrugged birth – despite her ob’s wishes.

Why is it that women feel this way and have this experience? Why is it that women don’t trust their obs or the medical establishment? Why is it that the C-section rate in the US is among the highest in the world? Why is it that our neonatal mortality is also among the highest in the world?

Maybe it would behoove you to contemplate these realities, instead of railing against a community that as a community actually respects women’s voice and choice.

Submitted by Caitlin Shannon, JD, MPH on July 23, 2008 – 10:53am.

CDC Wonder statistics

Has the US government data, posted by Dr. Amy, been published in a peer reviewed journal? Looks like it’s all based on birth certificates. Is it not? There’s a lot of problems with drawing conclusions based on birth certificate data, isn’t there? Isn’t that why researchers prefer prospective studies?

Submitted by Anonymous on July 22, 2008 – 12:13am.

Re: CDC Wonder Statistics

Anonymous – You’re exactly right. (Here is the link to the query http://wonder.cdc.gov/lbd-icd10.html so everyone can search it for himself.)

In 2003, of the 19 deaths, 4 were listed as being due to chromosomal abnormalities, 1 was due to encephalocele (part of the brain protrudes from the skull), 4 were due to heart defects, 1 was due to thanatorphic short stature (a rare genetic problem that affects 1/20,000-50,000 births, and is almost always fatal — either stillbirth or shortly after birth), 1 due to osteogenesis imperfecta, 2 to congenital diaphragmatic hernia, 2 due to “multiple congenital malformations” and 1 due to an unspecified congenital malformation.

In 2004, of the 10 deaths, 1 was due to anencephaly (the brain does not develop normally, and has an almost-100% death rate in the neonatal period anyway), and 2 were due to other chromosomal abnormalities.

While it’s possible they may have lived had they been born in the hospital, it’s impossible to know without knowing the cases, since many chromosomal and congenital birth defects are lethal, and birth place and manner have little or nothing to do with whether these babies survive or not.

What is *far* more likely is that these home-birthing women chose not to have any prenatal testing done (including ultrasounds), and did not know their babies were affected prenatally. Since most women who go to doctors do have these tests, they know their babies cannot survive or will survive with severe disabilities. Many of these women (even if they are nominally pro-life) choose an abortion or pre-term induced delivery (aka “life-birth abortion”) rather than carry the child to term and risk the uncertainty of stillbirth, intrapartum death, or neonatal death. (Check out http://www.BeNotAfraid.net for women who have not chosen abortion even when faced with the heart-breaking prenatal diagnosis [some of which were wrong].)

I’m actually unsure where Dr. Amy got her figure of 1.15/1000, because when I put in those criteria, I got 29 deaths out of nearly 30,000 births in the home-birth set, which is 0.98. When I realized there is a “non-hispanic white” in addition to “white” It dropped 2 deaths and about 4,000 births, for 1.05. (I’m assuming that when she says “20-45″ that she means 20-44, because it goes “45-49″, but this discrepancy may be where she gets her 1.15.)

However, of the 29 deaths, 20 of them were due to congenital defects or genetic problems — all of which may have been hopeless cases, regardless of birth place. It just can’t be known without investigating each of the deaths. When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:

CNMs: 0.25
MDs: 0.33
DOs: 0.34
other midwife: 0.34

You will have to figure the “other midwife” death rate, because of the small number, the rate is suppressed. Oh, yeah, homebirth is risky. Not!

I will also point out that the database lists “other midwife” as the birth attendant for over 5,000 in-hospital births at 37+ weeks, that there were 82 out-of-hospital Cesareans performed, and that CNMs performed some 6,000 in-hospital C-sections. Except that direct-entry midwives don’t attend hospital births (which is one reason for the difference in training they get, compared to other countries’ midwives), C-sections always take place in hospitals, and CNMs don’t do C-sections. So I’m unsure how accurate the data are.

Submitted by Katsy on July 23, 2008 – 9:32am.

That ALSO show that homebirth increases the risk of death

“When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:

CNMs: 0.25
MDs: 0.33
DOs: 0.34
other midwife: 0.34″

What you’ve just shown is that homebirth with a DEM has the same neonatal death rate as low, moderate and high risk hospital birth with an MD, (including all pre-existing medical conditions, and all possible pregnancy complications). That’s yet another indication that homebirth has an excess rate of preventable neonatal death. For an accurate comparison, you need to go back and pull out all the pre-existing conditions and pregnancy complications in the MD group (and the CNM group) and recalculate. When you do that you find that the neonatal death rates per 1000 are:

CNMs: 0.21
MDs: 0.24
other midwife: 0.34

No matter how you slice and dice the data, the conclusion is still the same. The most dangerous form of planned delivery in the US is homebirth with a direct entry midwife.

Submitted by Amy Tuteur, MD on July 23, 2008 – 11:03am

Um, yeah

Dr. Amy, you said that legalizing non-nurse midwifery will ultimately bring about the death of it. Why, then, do you not support such legalization in the states that do not yet have it? Isn’t the end worth it, in your eyes?

Besides, I think I pretty easily showed that so much of the “excess” neonatal mortality rate is, at most, 0.09/1000, excluding genetic and birth defects. (And that’s without doing any statistical calculations to determine if the rate is significant or possibly only due to chance.) It also includes the 4 deaths from the possibly higher-risk 42+ week group. Unless, of course, going post-term is *not* a risk factor. It confuses me, to speak plainly, because I always assumed you would think post-dates is not low-risk, yet you included it in the so-called low-risk births you culled from the CDC stats. Excluding the 42+ week births actually makes the “other midwife” statistic the lowest NMR!

How can that be?? I thought that “no matter how I sliced and diced the data” that such births were the riskiest form of planned birth! But in all seriousness, if 400,000 women chose home birth, at an apparent 0.09/1000 excess NMR, that would be an excess of 36 deaths, not 400-800 per year. If there were a current rate of 1% (40,000 births), there would be an excess of 3.6 deaths per year.

You’ve stated “the issue is safety”. Is it? Really?? Look at the data for 2004: there is an excess of neonatal death of 3-4/1000 for both maternal smoking and being unmarried. Instead of roaming the blogosphere trying to convince some 20-40,000 women to give birth in the hospital, why not spend that time convincing just 1,000 women to give up smoking? You’d be likely to be more successful, while ostensibly saving as many babies’ lives!

This study found there to be a nearly three-fold neonatal mortality rate when comparing C-sections to vaginal birth (1.77 vs. 0.62); and even when excluding certain risk factors such as congenital anomaly, the difference was “reduced only moderately.”

Considering that a woman who chooses a home birth has probably less than a 5% chance of ending up with a C-section (typically about a 10% transfer rate, and most don’t end up with a C-section), compared to a 23.6% chance at a hospital, that makes a C-section about 5 times as likely to happen at a hospital for low-risk women. So, if these hypothetical 10% of low-risk women chose home birth, and reduced their chance of a C-section to 1/20 instead of 1/4, then there would be only 20,000 C-sections, instead of 100,000. Also, reducing “moderately” the figures in the above-mentioned study (to exclude fetal anomalies, etc., giving C-section a hypothetical 1.4 NMR instead of 1.77), the excess 80,000 “unnecesarians” would yield an excess 62 neonatal deaths. (There would be a predicted 1.4/1000 for 100,000 C-sections, or 140 deaths, vs. 28 deaths out of the 20,000 C-sections; plus 0.62/1000 for the 300,000 or 380,000 vaginal births.) So, even if home birth yields an excess of 0.09/1000 deaths for low-risk women, and 36 babies out of a hypothetical 400,000 died, over 62 others would live that would have died, because they had been born by C-section.

So, the current neonatal mortality rate in babies born to low-risk women by (many times unnecessary) C-section is almost doubled that of the same hypothetical group that chooses a home birth.

Safety? Yeah, right.

Submitted by Katsy on August 2, 2008 – 12:43am.

Amy, Amy go away … take your lies and slither away

Amy,

Aside from the fact that you are grossly misquoting and twisting the scientific evidence to suit your one-man-band effort to discredit Certified Professional Midwives, we’re all so curious about who you are.

Where do you practice? What experience do you have with research? What are your research credentials? What are your research/academic affiliations? In short, aside from misquoting others’ statements and engaging in unsupported conjecture, what credentials do you have to back up your opinions?

Oh, and by the by, if you can tear yourself away from your solo efforts backed by Big Medicine to stamp midwives and home birth from the earth, do tell what you and them are doing to *fix* the critical problem in our society where nearly 1 in 3 American women are going through major surgery to give birth, but only a fraction of them are “high risk.”

Other than bashing the science-backed profession of Certified Professional Midwives with your club of lies, tell us what you’re doing to improve our current U.S. maternity care system. Explain what your doing in light of a two-year review of the science behind maternity care that indicates that the common and costly use of many routine birth interventions, such as continuous electronic fetal monitoring, labor induction for low-risk women, and cesarean surgery, fail to improve health outcomes for mothers and their babies and may cause harm.

Other than shoveling your horse manure all around the blogosphere, tell us what you’re doing when faced with this research that also finds that harm is caused by routine use of intravenous fluids (IVs), amniotomy (breaking the bag of waters), withholding food and water from women in labor, and episiotomy (http://www.medicalnewstoday.com).

And truly, if as you so falsely assert every time the wind blows, CPMs are such back-asswards health professionals, do tell us why the American Public Health Association (APHA) recognizes the CPM training and clinical skills assessment process as the basis of a national certification program for licensing midwives who provide out-of-hospital maternity care services.

Help us understand why states are increasing passing legislation to license CPMs, and why no state has ever reversed its decision to license CPMs. Also, please expound on why no state has reported an excess of damaged babies after permitting CPMs to practice or that all states reporting results have described favorable outcomes for mother and baby, and reduction in expense to the state for initial and follow-up care. Please pontificate on why eight of the ten best states in perinatal mortality license CPMs.

But you won’t go there, will you? My guess is the AMA and ACOG only pay you enough to buy and beat the one-note drum you’ve got … and because they can’t generate any answers to what they’re doing to fix the crisis, neither can you. So all you have is this feeble, tedious, obvious attempt to discredit midwives and the consumers who choose them.

Hey, I know: request a pay raise from Big Medicine (the AMA is a *$280 Million* organization after all), and maybe you’ll be able to talk about the other multiple aspects of improving birth in our society … oh, but that couldn’t be. You wouldn’t know how to talk about anything other than “me-Amy-you-second-class-inferior-midwife-because-I-say-so.”

But the good news? There is only one of you, (funny how *no* other MDs show up in blogs other than you to talk about this issue) and there are THOUSANDS of us and our numbers are growing … us being consumers and midwives (increasingly Certified Nurse Midwives (CNMs) … now doesn’t that just bite your bippy!?) … oh, and chiropractors, and naturopaths, and acupuncturists, and nurse practitioners, and massage therapists and childbirth educators, and lactation consultants, and doulas, and, and, and … and everyone who says “AMA/ACOG: BACK OFF. NOW.”

Amy, we know who you are. We’re just not that impressed.

As one of my mentors always says, “If you don’t have any solutions to the problem, get OUT of the way of those of us who are actually doing the work to fix it.” Beep, beep lady.

Steve U. in NY

Submitted by Steve U. on July 22, 2008 – 2:06am.

Access to Care – It’s Just a Go Do It

Thank you Ms. Clark for the thoughtful essay. Kudos to Dr. Dorn, Dr. Allemann and Dr. Binkley for supporting a woman’s right to birth as she chooses and to assure she has access to care.

This is very simple. Some women will choose to birth at home. We know it is a perfectly valid choice and these families deserve access to care and licensing assures the standards of care are maintained. There are very few physicians who will attend women who birth at home. Of the ~11000 CNMs in the US, only about 100 attend women who birth at home. The primary healthcare professional attending these families, and the only credentialed caregiver explicitly trained in the home setting, is the CPM. There are approximately 1400 CPMs serving women who choose to birth at home and the community of practice is growing at a steady rate year after year.

I absolutely support vigorous discussion on the subject of safety (informed consent is absolutely key), but it really bothers me when this most vocal adversary knowingly misuses the data. This has been debated for years and Amy knows darn well that just looking at stats for White Women is not appropriate. The data on the CDC Wonder site for white women birthing with Other Midwife will include the Plain folk which represents ~10% of the home birth population with higher incidence of congenital anomalies. Also, risk profiles are not the same and we know that there are women with known breech presentation who are birthing at home as they will not be supported in a vaginal breech birth in hospital. I think it is terrific that obstetrics has advanced such that planned C/S is likely the safest option for breech presentation, but when women run out of options in the hospital they will look for options elsewhere. Indeed, Schlenzka observed better outcomes for midwife attended Out-of-Hospital birth even with elevated risk factors. We know that the incidence of low birth weight babies is lower for midwife attended planned home birth due to better maternal health. We know the C/S rate is reduced by a factor of 5 which will result in fewer hysterectomies and maternal deaths. The incidence for all of these bad outcomes is very low, but it is simply argumentative to claim that hospital birth is safer for healthy women experiencing normal pregnancies.

On the subject of training, a comparative evaluation was recently performed by the Director of our University CNM Program and presented to a legislative study committee. This assessment compared the minimum clinical requirements to obtain the CPM credential, the CNM credential and the CM credential (the ACNM version of the Direct Entry Midwife). The conclusion was clearly that the clinical requirements are comparable for care during the childbearing year. More importantly, the CPM credential is accredited by the National Organization for Competency Assurance (NOCA) which is the same organization that accredits the CNM credential.

It is clear that the leadership of the ACOG/AMA has lost all perspective and I find their priorities in establishing their agenda remarkable. In my state, we lose ~1500 babies per year during the perinatal period. The biggest source of excess bad outcomes is poor maternal health resulting in over 200 excess bad outcomes per year. A conservative estimate for the total number of bad outcomes for women who choose to birth at home is 3-5 per year from all causes and largely not preventable. Furthermore, 8 of the top 10 states in perinatal mortality license CPMs and there are women who are birthing unassisted because they do not have access to midwives.

Assuring women who choose to birth at home have access to care is just a go-do-it. Advancing access to the Midwives Model of Care is good policy and will promote improved maternal health. It is also important for the safety of these families that transfers of care are efficient and unobstructed when obstetrics is indicated which can only happen with licensed midwives.

I’m finding that the legislators tend to see the logic in all of this and that the obstructionists must resort to strong-arm tactics to delay the inevitable (access to licensed midwives). It’s funny, if the Medical Societies were to actually support this community they would find allies in their initiatives to address the environment in which obstetrics is practiced. Instead their leadership is entrenched and we will bump heads in front of the General Assembly and the media and they will lose.

Russ Fawcett
Legislative Chair, North Carolina Friends of Midwives

Submitted by Russ Fawcett on July 22, 2008 – 9:56pm.

Interpreting Data

It’s not just my opinion. Other groups who are really good at looking at data have made recommendations based on the scientific evidence. Of course midwifery organizations such as ACNM (American College of Nurse Midwives), MANA (Midwives Alliance of North America), NACPM (National Association of Certified Professional Midwives),CfM (Citizens for Midwifery) CIMS (Coalition for the Improvement of Maternity Services) and the Big Push for Midwives advocate for midwifery care in hospitals, birth centers, and in homes. Midwives would be expected to believe in midwives. But there are neutral organizations which support midwifery care and out of hospital births. The APHA (american public health association): “Therefore, APHA
Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services,” WHO (world health organization) outlines care for pregnancy around the world (http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf): Scroll down to page 4 to see who they recommend should provide the care–its midwives or people with “midwifery training” in EVERY situation involving a pregnant, birthing, or postpartum woman. NEVER a doctor without a midwife, even when the woman has become very very sick.

The RCOG (The Royal College of Obstetricians and Gynecologists) and the RCM (Royal College of Midwives)–groups in England have this to say about home birth and midwives:
“The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that
labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.1–3 ”

Unlike the ACOG statement and the AMA resolution, these organizations quote many scientific studies. I call that “interpreting the data”, maybe I’m not using that term correctly, but I sure agree with these expert groups in their conclusions. They spend a lot more time studying studies than I do.

To quote a more powerful expert: I recently had the privilege to attend the birth of a physician (the mother is a physician–we shall see what the baby becomes) who is very familiar with all these studies and the arguments about what they mean. She pushed out her son into a tub of water, greeted him joyously, and moved to her bed to nurse. Three hours later as I was waving goodbye from the doorway of her bedroom, she said “This changes everything!” Indeed.

Elizabeth Allemann, MD

Submitted by Elizabeth Allemann, MD on July 23, 2008 – 7:59pm.

Take the time to get and read your records.  You may find that your “emergency” cesarean was no rush at all.

Medical Records Copying Charges by State

Here is Florida Statute Number 627.6574, but it’s section 7 that spells it out very clearly.  I’ve bolded it for your reading pleasure….

1) Any group, blanket, or franchise policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.
(2) Any group, blanket, or franchise policy of health insurance that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.
(3) This section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by an insurer.
(4) Any group, blanket, or franchise policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician’s office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.
(5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process that includes a written protocol for utilization review and quality assurance.
(6) An insurer subject to subsection (1) may not:
(a) Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section.
(b) Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.
(c) Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.
(d) Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(e) Subject to paragraph (7)(c), restrict benefits for any portion of a period within a hospital length of stay required under subsection (2) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.
(7)(a) This section does not require a mother who is a participant or beneficiary to:
1. Give birth in a hospital.
2. Stay in the hospital for a fixed period of time following the birth of her infant.
(b) This section does not apply with respect to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.
(c) This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (2) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.

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.”

This is great info for women of those states! 

Compliments of Our Bodies Ourselves: Finding and Comparing C-Section Rates by Hospital

Want to know if your doctor has been subject to a board hearing or disciplinary note? 

Here is a link to the State Board sites for all 50 states.

The strength of this letter lies in a few key pieces of information.  First, it cited state law.  Research the laws in your state as they relate to midwives as some states compel insurance companies to cover midwives.  Also, research your state laws to see how they handle gaps in insurance coverage.  If your insurance does not have a contracted home birth midwive within your area, you can argue that there is a gap of coverage and thus appeal to your insurance to cover the home birth midwife you hired.

Second, cost effectiveness.  Homebirths are less expensive than hospital births and since insurance companies are all about reducing costs, this should be compelling to them.  The typical hospital vaginal birth runs about $7,000 which is way more than the typical homebirth midwife who charges between $2,000 – $4,000. 

Third, homebirth is a healthier option by eliminating the elevated risk of cesarean section one faces simply by setting foot in a hospital, eliminating all the risk that routine hospital procedures introduce, as well as eliminating the chance of catching a hospital acquired infection such as MRSA.

**************************************8

December 7, 2007

CIGNA Health Care
National Appeals Unit
P.O. Box 5225
Scranton, PA 18505-5225

Dear Sir or Madam:

This letter is in response to the denial of coverage for the prenatal care, labor and delivery, and post partum care surrounding the birth of my daughter XYZ on MM/DD/YY.

At the time that my wife and I started attempting to conceive in mid 2006, CIGNA was contracted with an out of hospital group of midwifes called ABC. This was the group that we used when my son was born and we found them to be an excellent alternative to the costly hospital birth. We found out later in the year, after my wife was four months pregnant, that ABC would be closing at the beginning of the year, more than four months prior to my daughter’s birth. At this point I contacted CIGNA to determine what other non hospital birth option would take their place. I was told that whatever contract changes would be made would probably not be in place in time for our birth.

This gap in coverage in our area (since there are non hospital midwife options outside our area) forced us to decide weather the healthiest option would be a hospital birth or out of network midwife. Due to the many health issues surrounding a stay in the hospital, from sleeplessness to super bugs like MRSA, we determined that the healthiest and most cost effective birth option was homebirth with an attendant midwife.

I understand that in contracting with ABC CIGNA was trying to provide an in network provider in Orlando that was commensurate with the in network providers in other areas of Central Florida. I also understand that the gap in coverage created by the closing of ABC was unforeseen by CIGNA. I do believe that this kind of gap in coverage is covered here in Florida under Florida Statute 627.6471 which states:
“If any service or treatment is not within the scope of services provided by the network of preferred providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to preferred providers. The reimbursement rate must be applied to the usual and customary charges in the area.”

Here in Florida, the desire to have a more natural birth, either using a birthing center or a Certified Nurse Midwife, is clearly evidenced by other Florida Statutes like 627.6406 which states that:
(1) Any policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.

Clearly it is in the best interest of my company to keep costs low for health insurance. The cost for an OB/GYN to do the prenatal care, a hospital birth with attending physicians, and the following
stay in the hospital, would clearly have cost 3 times the $3100 I had to pay for the care and delivery of my daughter. And that’s if nothing went wrong.

It seems that it would be in the companies best interest to facilitate this less expensive option any time it is medically feasible to do so. I don’t know how the delivery would have gone if we had acted solely on financial decisions and gone to a hospital. I’m sure it would not have been anything like the birth we experienced. With a 33% rate of cesarean births here in Florida there is a very good chance it would have involved surgery. What I do know is that at one week shy of six month old, my daughter has pulled herself up to standing for the first time. I could not ask for a healthier, happier baby or a quicker more complete recovery for my wife. These are the reasons that this option is so important to the people here in Florida and to us specifically.

Thank you for reconsidering coverage of the birth of my daughter.
Sincerely,

Cc: (name removed), Human Resources
Enc: Midwifes notes