Henci,

As you are aware there is a common misconception that there is statistical proof that maternal requests for c-sections, with no medical basis, is increasing. My question to you is: what other explanations are possible for the increase in non-medically necessary c-sections?. Also, is it true that most insurance companies do not cover elective c-sections?

Thank you! By: Adriane

Apologies, but I'm trying to finish up a project with a hard deadline. I'll respond as soon as I can.

-- Henci By: Henci Goer

Yes, of course, I am. I was at the so-called NIH State-of-the-Science conference that made the completely unfounded assumption that cesareans without medical indication were all at "maternal request" and persisted in it despite clear evidence to the contrary. At that conference -- and ignored in the final report -- were the results of the second U.S. national Listening to Mothers survey taken of women giving birth in 2005. This is the only research to date that actually asked women about this issue. It found that less than 1/10th of a percent of respondents requested a first cesarean. By contrast, 9% of women reported pressure to agree to a cesarean. Meanwhile, over half the women who wanted a VBAC were refused that option. It seems a woman's right to choose how she wants to give birth only extends to saying "yes" to cesarean surgery, but not "no." You can read more about the results of this survey at Mothers Report Cesarean Views and Experiences on the Childbirth Connection website. There is also an article downloadable from the Lamaze International website entitled The Problem with Maternal Request Cesarean.

Also in the NIH report were reasons its authors felt were sufficient justification for major abdominal surgery on a healthy woman. As comic columnist Dave Barry used to say, I am not making this up:

-- "need to be in control of the birth process" although I can't think of a time when one is less in control than while undergoing surgery

-- "a health care provider’s . . . training, practice environment and experience, personal philosophy regarding birth, and medical-legal experiences." That last one is a glaring conflict of interest.

-- "availability of anesthesiologists or operating room staff for cesarean delivery"

-- "economic considerations, such as insurance coverage, payment, and scheduling conflicts"

and my personal favorite:

-- "the unpredictability of the timing and length of labor for a health care provider’s lifestyle and fatigue level"

You can download the NIH final report and read it for yourself. And then you can read a superb deconstruction of it, also on the Childbirth Connection website. Read it and weep -- or laugh -- or both.

I don't know whether insurance companies cover elective cesarean surgery. They probably don't, but it hardly matters. Enterprising obstetricians can always come up with something to put in the "indication" box. And, in fact, one of the recommendations made in the NIH report was to institute a diagnostic code for maternal request cesarean. Since the physician would be checking the box, we wouldn't actually know who initiated the c/sec, but once there is a diagnostic code, insurance companies would have to pay.

-- Henci

By: Henci Goer

so these c-sections that are not medically necessary are or are not being covered by insurance? or are doctors hiding medically unnecessary c-sections in with those that are medically necessary in order to get insurance coverage? By: Adriane

Cesarean surgeries done for any of the reasons I listed from the NIH report or for any reason that does not relate to the woman's or her baby's health are, by definition, "medically unnecessary." I would bet that every one of the elective first cesareans in this country is covered by insurance or paid for out of pocket. Do you seriously think obstetricians would do them for free?

As for "hiding" them among the "medically necessary" cesareans, the bigger issue is how many cesareans are medically necessary? If the only cesareans that got done were the ones that were medically necessary, the cesarean rate in the U.S. -- or any other country, because this is a worldwide problem -- would be less than 15%, which would be half or less of the cesarean surgery rate here. That 15% maximum was established at a World Health Organization consensus conference in 1985, which concluded that based on countries with the best perinatal mortality rates, a cesarean rate of more than 10-15% could not be justified. Since that time, dozens of studies have confirmed that rates below 15% can be achieved in the usual mixed population of women who have complications and women who don't and women having first babies and women with prior births without any detriment to maternal or newborn outcomes. In fact, mothers and babies -- and certainly future babies -- are healthier because they have not been unnecessarily exposed to the dangers of major surgery or the risks of a scarred uterus. The short version of the take-away message for all this is: "If you don't want to get cut, don't go to a surgeon."

-- Henci By: Henci Goer

No, I'm quite sure OBs are NOT doing cesareans for free I wasn't implying that.

A group of students in my nursing class did a presentation on "maternal request" c-sections. Their presentation was based on the false belief that we had statistical data to prove they are increasing significantly. They also stated elective c-sections were not covered by insurance companies. So IF this was true, it didn't make a good case for "maternal request" c-sections increasing dramatically because who has enough money to pay for that kind of thing out of pocket?

Thank you for your help. It is much appreciated. By: Adriane

You're welcome. I hope my first response and the sources I recommended gave you enough ammunition to refute the nursing students' presentation.

There is a real danger, however, that the active promotion of elective 1st cesareans by OBs on the false premises that cesarean surgery is just as safe or almost as safe as planned vaginal birth and that it will protect the pelvic floor will, over time, convert the current imaginary groundswell into a real one.

-- Henci

P.S. I didn't really think you thought OBs would do c/secs for free. It was a rhetorical question to make exactly the point you made. By: Henci Goer