Money running out for convenience caesareans

AIMS Journal 2002, Vol 14, No 3

The leading British health insurer AXA PPP Healthcare has said it will no longer pay for caesarean births because of uncertainty over whether the procedure is medically necessary. Pat Thomas reviews the situation.

Health insurer AXA PPP believes it has become increasingly difficult to distinguish between medically necessary caesareans and those carried out for personal preference. Other major health insurance providers, however, say they will continue to pay for caesareans if they are medically necessary.

According to Department of Health figures, one in five babies in the UK is delivered by caesarean.

Some observers suggest that the trend for busy celebrity mothers - for instance, ex-Spice Girls Victoria Beckham and Mel B, All Saints singer Melanie Blatt, deejay Zoe Ball and actress Patsy Kensit - to opt for surgical delivery has had an influence on the thinking of normal women leading normal lives. Doctors increasingly report that 'women's choice' is the reason for performing so many unnecessary caesareans-though what influences this 'choice' has not been the object of much scrutiny. PPP's move will certainly add to the debate over normal vs surgical birth and the rising rate of unnecessary caesarean operations.

Other health insurers have not yet followed PPP's lead though they, too, are being more selective in what they will and will not pay for. Dr Natalie-Jane Macdonald, medical director of BUPA, has said: "Our way is to cooperate closely with consultants and our women members to make sure we fund only those that are clinically justified."

But Dr Adrian Bull, medical director of PPP, stands firm: "Previously, we covered those cases that were considered a medical necessity. But it has become increasingly difficult to distinguish between these and convenience caesareans. More than half the babies born in private hospitals are delivered by a caesarean and we feel the operation is becoming routine, rather than genuinely necessary."

News of PPP's new policy caused only mild debate in the press. One commendable article written by Christine Doyle of The Daily Telegraph (12 November 2002) broadly acknowledged that, while PPP's decision was probably inevitable and may, in the end, force a rethink concerning unacceptable caesarean rates, some women will lose out. Should all insurers eventually follow suit, women who have medically justifiable caesareans won't be covered.

Doyle's article included useful input from many authorities. Professor James Walker, of the Royal College of Obstetricians and Gynaecologists, noted that, while caesareans are much safer than they once were, there are still unappreciated longterm risks. "We could be building up troubles for the future, but often the risks are not discussed," he commented.

Professor Walker also noted that pregnant women carrying breech babies are frequently advised to have an emergency caesarean. However, the reason for the increased number of such operations may, in part, be that fewer midwives now have the confidence to deliver breech-birth babies vaginally-a point of view AIMS has been hammering home for years.

Mary Newburn, policy director of the NCT, says that reducing the number of first-time caesarean births was the key to reducing the rise in caesareans. She also commented, "We would like to see more midwife-led units, where women are encouraged to see childbirth as a normal physiological process." Amen.

No one who has watched the trend for more caesareans closely was at all surprised at PPP's assertion that most of them take place in private hospitals. When AIMS Chair Beverley Beech's book Who's Having Your Baby? (Camden Press, 1987) first came out, her assertion that private hospitals had unacceptable rates of all kinds of interventions, most of which were paid for through insurers, seemed provocative. Subsequent research has shown the assertion to be true.

Today, at the fashionable Portland Hospital, which delivers 2000 babies a year, around 44 per cent of mothers have a caesarean-twice the national rate. More than 60 per cent pay for the operation themselves.

In hospitals like this, caesareans are big business, and there is a financial incentive for doctors to encourage women to have them. By taking the financial incentive away, PPP are making a bold move that may finally cause the powers that be to rethink their far-too-lax policies on caesareans.

AIMS replies

Christine Doyle's article included a brief list of the advantages and disadvantages of caesareans (see box below).

On 14 November, The Daily Telegraph printed AIMS Chair Beverley Beech's reply to the article:

Sir: The risks of caesarean delivery for mother and baby are greater than indicated in your article (Health, Nov 12).

Normal vaginal birth, including exposure to the mother's hormones in labour, helps the baby's future development. Moving through the birth canal reduces the risk of breathing problems in infants. Caesarean mothers are less likely to be able to breastfeed and breastmilk improves the baby's immunity and IQ. All drugs used for pain relief reach the baby, and studies from Sweden and America have shown that drug exposure during birth increases the risk of the child becoming a drug addict in later life.

Every caesarean birth leaves a scar that increases the risk in any future child, or mother, of a ruptured uterus, or haemorrhage from an embedded placenta. Since more women now have a scarred uterus, emergency caesarean hysterectomies have increased, and we have had a number of calls from devastated mothers whose lives were saved, but are unable to have another child.

The risk of postnatal mental illness is also higher in caesarean mothers - including post-traumatic stress disorder after emergency sections. Many such mothers have told us that their emergencysections were caused by: not being enabled to have a normal labour, having labour speeded up by drugs, being prevented from moving around and adopting the position of their choice. Meanwhile, distressed midwives call to tell us they are leaving the profession =because the high-tech production line has taken over normal birth and they have been turned into obstetric nurses.

Statistics from several countries show that private obstetric care greatly increases the chances of a woman having a caesarean. If insurance companies are refusing to pay for even "medically necessary" private sections, it could be because they have at last learnt that obstetricians' judgments can be influenced by their bank accounts as well as clinical needs.

ADVANTAGES

• Convenience. Pregnant women and doctors can plan so that babies are delivered at civilised hours, when maternity units are fully staffed.
• A sense of control.
• Freedom from exhausting, painful contractions.
• A pain-free return to sexual activity. No stitches are required.
• It prevents tearing and stretching of pelvic tissue, which might lead to incontinence. Studies show a higher incidence of incontinence in the mothers of vaginally delivered babies, though pregnancy itself also increases the risk.
• Well-planned elective caesareans can save babies' lives, and have contributed to a lower perinatal and disability rate during the past 25 years.

DISADVANTAGES

• Higher rate of complications such as clotting and haemorrhaging
• Longer recovery periods for mothers
• Risk of infection
• Scarring and adhesion can lead to repeat caesareans and an increased risk of needing a hysterectomy later
• Lowered fertility. A recent British study analysed how long it took women to conceive a second child. Two-thirds of the women who took more than a year had had their first baby delivered by caesarean