As research shows the risks of delivering babies before they’re ready, insurers from Aetna Inc. to Cigna Corp. are nudging hospitals and doctors to scale back induced births and cesarean surgeries.
A decades-long move toward scheduled births has helped make the C-section the most common surgery in the U.S., accounting for a third of all deliveries, according to federal statistics. More troubling, the procedures are coming earlier in pregnancy, raising costs as well as the risk of complications. Insurers are starting to push back.
“We’ve known the risks of these procedures for a long time, yet the rates continue to rise,” said Maureen Corry, executive director at Childbirth Connection, a New York-based advocacy group focused on maternity care. “The payors are finally saying, ‘Enough is enough. This is crazy.’”
As costs climb, insurers are shedding a reluctance to intervene in an area as sensitive as childbirth, Corry said. Aetna, the third-biggest U.S. health plan, is seeking to adjust prices for cesareans, which now earn hospitals as much as twice the rate of traditional deliveries. Cigna is considering a similar move, along with bonuses for hospitals that reduce early C-sections and inductions.
Carriers led by UnitedHealth Group Inc., the biggest U.S. insurer, gave $60,000 in 2009 for a symposium on maternity care run by Childbirth Connection, a 94-year-old nonprofit mostly funded by foundation grants. States are taking action as well: Texas lawmakers voted last year to limit payments for the procedures from Medicaid, the health program for the poor.
The average cesarean birth cost $24,300 in the U.S. last year, compared with $15,200 for a vaginal birth, according to the London-based International Federation of Health Plans.
The industry efforts, joined by public-health groups and charities like the March of Dimes Foundation, come as early births not only proliferate but move further from the 39 weeks considered optimal for single-baby pregnancies.
“It’s been a slippery slope where we’ve said ‘Let’s induce at 39 and a half weeks. OK, that worked well, let’s try 38; let’s try 37,’” said Elliott Main, chairman of obstetrics and gynecology at California Pacific Medical Center in San Francisco. “Year after year, it’s gotten pushed back.”
C-sections and inductions have risen for a variety of reasons. Women are giving birth later in life, patients and doctors are seeking more convenience and payment systems often favor intervention. There’s also been a growing sense -- false, based on recent research -- that cesareans offer a risk-free alternative to natural birth, said Patricia Stephenson, a senior medical director at Bloomfield, Connecticut-based Cigna.
“Society is becoming increasingly convenience-oriented,” said Stephenson, a former obstetrician. “If there’s any concern about the pregnancy, if the mom is uncomfortable, it’s been, ‘Sure, why not? Just suggest an early delivery.’”
The procedures, of course, make sense when the health of the mother or baby is at risk. C-sections, for example, may be necessary for breech babies improperly positioned in the birth canal or when women suffer from severe high-blood pressure, according to the American College of Obstetrics and Gynecology.
Still, such cases can not explain the rise to a record 33 percent of U.S. babies delivered by cesarean in 2009, the latest figures available from the U.S. Centers for Disease Control and Prevention. Induction rates rose to 23 percent that year, doubling over two decades, the Atlanta-based CDC said.
The U.S. isn’t alone in bending Mother Nature to modern medicine. Cesarean levels have reached “epidemic proportions” in many countries, the World Health Organization said in a report two years ago. The U.S. rate is on par with some Latin American nations and Australia but well ahead of the U.K., France and Norway, all with cesarean rates at 22 percent or less, the WHO said.
The backlash against the procedures has spawned its own website, The Unnecesarean, where San Diego mom Jill Arnold shares tales of women who felt pushed into C-sections.
Arnold, 38, was persuaded by doctors to schedule a cesarean in 2005 after being told her baby might be too large, she said. She went into labor before the operation and delivered her daughter, Maggie, normally and without incident.
Two years later, she gave birth to a second girl, Molly, at an independent birth-center where she felt “more in control.” She started the website after hearing from other mothers who felt pressured while finding more research that questioned the approach.
“They feel either lied to or deceived or that they were pushed really heavily in one direction and later found out the medical indication wasn’t there,” Arnold said. “They feel they were railroaded.”
It’s only recently that research has shown the tradeoffs of cutting pregnancy short by a few days, Stephenson said. A 2009 study in the New England Journal of Medicine found rates of medical problems doubled for children born at 38 weeks compared with those delivered at 39 weeks. At 37 weeks, the risk of complications, including breathing problems and infection, rose by as much as four times. The study was sponsored by the National Institutes of Health.
Inductions can lead to longer, more painful deliveries that studies show are twice as likely as spontaneous labor to end in a C-section, said Main, the San Francisco doctor.
While there is no nationwide count of the practice, a survey of hospitals last year by the nonprofit Leapfrog Group found 14 percent of C-sections and inductions were performed for nonmedical reasons before 39 weeks. That may underestimate the phenomenon, since hospitals that track early procedures are also likely to be the ones concerned about limiting them, said Erica Newman, a program director at the Washington-based group.
Among obstetricians, “people are worried” about the early births, said Joshua Copel, a Yale University professor and former president of the U.S. Society for Maternal-Fetal Medicine. “For anything elective, most of us believe that 39 weeks and zero days is the absolute earliest any delivery should occur.”
Insurers are trying to shift what Main calls the “perverse incentives” that push doctors to speed up deliveries. C-sections not only pay more; along with inductions they also allow doctors to cluster births and schedule other visits around them, he said. And they assure a physician will be on hand for a delivery -- and get the insurance payment -- when a baby arrives. Wary of litigation, many hospitals also refuse to do vaginal births if a mom has had a prior C-section, even when natural delivery is a viable option, Main said.
Aetna has renegotiated maternity payments with 10 hospitals around the country so far, bringing rates for cesareans and vaginal births closer together, said Tammy Arnold, a spokeswoman for the Hartford, Connecticut-based carrier.
The company is also highlighting hospitals that adopt guidelines designed to avoid elective births before 39 weeks, Arnold said in a telephone interview. So far, about 300 hospitals have won the designation.
Cigna is pursuing similar changes. While it expects some resistance from hospitals, research on the benefits of full-term births is winning over physicians, Stephenson said. The insurer has seen a decline in early elective procedures in the last few years, she said.
UnitedHealth has taken “more of a carrot approach,” said Tina Groat, the company’s national medical director for women’s health. While the Minnetonka, Minnesota-based insurer is considering bonuses for providers who reduce elective births, it has so far focused on educational campaigns, including videos and websites geared toward pregnant women.
Hospitals are acting as well, said Joanne Rogovoy, a state program director for the March of Dimes, the White Plains, New York-based charity seeking to reduce premature births. Since August, the group’s Oregon chapter has persuaded 34 hospitals in the state to bar elective C-sections before 39 weeks.
“We schedule everything,” said Rogovoy, who’s based in Portland. “We’ve just become complacent. And it’s only recently that it’s become clear how much of a difference a few weeks can make.”