Women with private health insurance are more likely to receive a medical intervention during childbirth, such as having their labor induced or undergoing a Cesarean section, than women with no insurance or whose medical coverage is through state Medicaid programs, according to a new study from the University of Minnesota.
Furthermore, the rate of the increase in obstetric interventions, particularly C-section deliveries, is increasing more rapidly among women with private insurance, the study found. And that difference was evident even after controlling for such factors as the woman’s age and race and for health issues associated with pregnancy- or delivery-related complications.
These findings are “troubling,” said Katy Backes Kozhimannil, an assistant professor at the U of M’s School of Public Health and the study’s lead author, in a phone interview earlier this week. “We don’t want the payer to be the one determining the type of care that women receive.”
A growing problem
Medical interventions during childbirth — especially the induction of labor and Cesarean sections — have been on the rise in the United States over the past two decades. From 1996 to 2009, for example, the C-section delivery rate increased from 20.7 percent to 32.9 percent, and the labor induction rate rose from 9.5 percent to 23.1 percent.
Meanwhile, the rates at which women are delivering a baby vaginally after previously delivering another baby by C-section — a procedure known as a VBAC (vaginal birth after Cesarean) — has plummeted, from 28.3 percent to 8.5 percent.
Cesarean deliveries are often, of course, lifesaving for mother and child alike, but the procedure is still major surgery, which comes with many health risks. The mother can develop life-threatening complications, including infections, uncontrolled bleeding, blood clots, and bowel obstructions. Women who have C-sections are also less likely to breastfeed and more likely to develop post-partum depression. For the baby, being born via a C-section increases the risk of respiratory and other lung problems, including asthma.
Medically unnecessary C-sections and other obstetric interventions (which often lead to C-sections) have therefore become a major concern of public health officials. As background information in the U of M study points out, the rise in obstetric medical interventions in the United States has coincided with a parallel increase in adverse birth outcomes.
For the study, which was published in the American Journal of Managed Care, Kozhimannil and her colleagues analyzed government-collected data on more than 6.7 million hospital-based births in 44 states between the years 2002 and 2009. The data is part of the Healthcare Cost and Utilization Project (HCUP), which is run by the Agency for Healthcare Research and Quality.
Some 54 percent of the study’s births included in the study were covered by private health insurance, and 42 percent were covered by Medicaid. Slightly less than 4 percent of the women in the study had no health insurance. Interestingly, the proportion of women covered by private insurance dropped by 14 percent during the seven years of the study while those covered by Medicaid rose by almost 21 percent.
About 39 percent of the births were to white mothers, 20 percent to Hispanic mothers and 10 percent to black mothers. Almost half of the births occurred in teaching hospitals, and only 11 percent were in rural communities.
An analysis of the data confirmed what previous studies had found — that uninsured women and women with Medicaid coverage are less likely to receive medical intervention — Cesarean delivery, labor induction, and episiotomy — during childbirth than women with private insurance.
The study also found, however, a more rapid rise in Cesarean delivery rates among privately versus publicly insured women during the past decade: 6 percent versus 5 percent.
“With Cesarean delivery being the most common inpatient surgery in US hospitals, this differential trend — although small in absolute size — has an enormous magnitude in terms of potential payer cost and public health impacts,” Kozhimannil and her colleagues write.
If the rate of increase in Cesarean deliveries had been the same among the privately insured women as among those covered by Medicaid, there would have been 41,614 fewer C-section deliveries in the U.S. in 2009, they point out.
Hospitals are not ‘evil’
The difference in cost between vaginal and Cesarean deliveries is significant. A study published earlier this year found private insurers paid an average of $27,866 for a C-section compared with $18,329 for a vaginal delivery in 2010. Medicaid paid significantly less for each procedure, but there was still a wide cost spread between the two: $13,590 for a C-section versus $9,131 for a natural delivery.
Kozhimannil does not believe, however, that physicians are making childbirth-delivery decisions for individual women based on whether the woman is privately or publicly insured.
“This is not clinician-driven,” she said. “I do think, however, that hospitals know what percentage of their births are covered by Medicaid versus private insurance, and I think that may affect how they guide and manage care in their units.”
Earlier this year, Kozhimannil and her colleagues published another study that found the rate of Cesarean-section deliveries varied widely — stunningly so — among U.S. hospitals, from 7.1 percent to 69.9 percent.
“I’m not saying that hospitals are evil,” Kozhimannil said, “but how we pay for [childbirth] does matter.”
Kozhimannil would like to see new policies and payment reform to minimize medically unnecessary obstetric interventions. There is some urgency to the need for such reform. Next year, as the implementation of the Affordable Care Act kicks into full gear, more women will have the option to choose private insurance.
And, as this new study’s findings indicate, that means more women will likely be experiencing medical intervention, including C-sections, during childbirth.