Friday, June 20, 2008

Making home birth illegal?

Much has been written this week about the American Medical Association, a trade association for doctors, drafting a resolution calling for the illegalization of home birth and blaming Ricki Lake for making it trendy with the film she and Abby Epstein made called "The Business of Being Born." (I highly recommend the film, which you can get on Netflix, and not just because I am interviewed in it. ;)

So I will try not to repeat what others, including Ricki, have said in response to the AMA, which boils down to a proverbial flip of the bird. Instead, I hope I can offer some context and history here.

1. The American Medical Association was a big part of the campaign to eradicate midwives nearly a century ago, a move that was largely successful, and this country is still grappling with the public health consequences of that -- with 99 percent of births taking place in a hospital; 1 out of every three births a c-section; and half the women in the hospital getting Pitocin. The campaign then was about money and power, as it is now.
2. I have NEVER heard a woman who has given birth at home say she made a mistake or that it was a horrible experience. If there are any such moms out there, I'd love to hear from you. By contrast, I hear more and more from women who have horrible hospital experiences with OBs who still think episiotomies are necessary and no woman should push for more than two hours.
3. Those who are against home birth will typically post on blogs with remarks that start like this: "My baby had shoulder dystocia...thank God I was in a hospital and that wonderful doctor saved me and my baby..." Well, guess what, that doctor probably performed the Gaskin maneuver, named after a MIDWIFE, who knows a thing or two about shoulder dystocia in home birth.
4. Throughout history, whenever women felt they did not have a choice in childbirth, they spoke out, voted with their feet, and forced change. Clearly, woman are beginning to feel pushed around, and many are choosing to stay home, in part, I hope, because they are being empowered by the FACTS, by scientific studies, by films, and by books such as mine and Jennifer Block's Pushed.
5. I had a home birth 6 months ago. It blew my mind. It was as birth should be and I am no radical. If home birth suddenly became illegal, and I suddenly became pregnant again, I would still find a way to give birth at home. Oops, guess I couldn't make it to the hospital in time. And you can bet that midwives would still come if called, regardless of the consequences. Tell me, how would illegalizing home birth do anything but force it underground and make it less safe?

Sunday, June 15, 2008

On Father's Day

I made an appearance in central Mass. the other night for a screening of the "Business of Being Born," an event organized by doula/Mothers & Co. owner Jeanette Mesite Frem. Jeanette was telling me that she is in a new film called "Being Dad," filmed by Australians and premiering in the US this summer. The film is meant to answer the question what should men expect when they're expecting?

To view the trailer, see:
I believe there are clips on YouTube, as well.

It's a great idea for a film. Whatever it takes to keep men connected and from saying things like, "Do you really want another piece of cake," when his wife is 9 mos. pregnant.

Meanwhile, today I got an email from Clay Nichols, who runs DadLabs, which is back from a five-day excursion to Stockholm to see first-hand the most dad-friendly place on earth. They were hosted by Baby Bjorn, who introduced the to politicians, daycare centers, and dads that have benefitted from Sweden’s progressive pro-family policies. DadLabs was most impressed with how connected to their children and happy with the paternity leave policy the dads of Stockholm were. The trip culminated with a meeting with the man behind the brand, Bjorn Jacobson.

Wednesday, June 04, 2008

Breakfast with Gloria Steinem

I had breakfast with Gloria Steinem this morning -- me and 1,000 other of her BFFs in Boston, at an event put on by The Commonwealth Institute, an organization that promotes women in business. She said a few things that really made me think. And a few things that really made me laugh, including: "I'd like to create a button that says 'The truth shall set you free, but first it will piss you off.'" Amen sistah.

She also talked alot about how family forms have a real connection to international and governmental relations. For example, the Native Americans had egalitarian family structures, where gender was never an issue. That lack of bias or set roles was reflected in their government, where female elders chose a chief and they could remove a chief. With three boys in the house, I will consider it a job well done if, when they grow up, they empty the dishwasher without their wives having to ask.

Later in the program a member of the audience asked her why younger women don't seem to appreciate all the hard-fought freedoms they have. This question posited -- without saying it -- why is this generation of women getting MBAs and then become stay-at-home moms? Gloria said she did not think young women don't appreciate their freedoms. It's just that women tend not to become activists about anything until they are older, and begin to feel their personal power slip away. Young women have all the power; they are fertile, pretty, etc., she said. As we age, all that changes.

Sunday, June 01, 2008

From today's New York Times, an absolutely outrageous tale of insurance companies denying coverage for women with previous cesareans. As always, it is money dictating the rules of health care. Of course, money (malpractice fears) is one of the reasons why the c-section rate in the US at 1 out of every 3 births. Honestly, it is surprising that it took insurance companies this long to wake up to the fact that they are paying either way -- for the c-sections that don't get done when they should, those that get done poorly (regardless of whether they were necessary) or when a woman is denied access to a vaginal birth after cesarean, which is happening more and more...

June 1, 2008
After Caesareans, Some See Higher Insurance Cost
When the Golden Rule Insurance Company rejected her application for health coverage last year, Peggy Robertson was mystified.

“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.”