The American College of Domiciliary
3889 Middlefield Road ** Palo Alto, CA 94303
March 4th 1999
Dr Jerry Frank, Senior Medical Director
Re: Nurse-Midwife Jeannette Beem and Aetna Policy on Domiciliary Birth Services
Dear Dr. Frank,
I have a copy of a letter dated 1/18/99 from your office to Ms Breen notifying her of your companys termination of her contract. According to your letter this decision was due to her provision of domiciliary birth services to low-risk women who had chosen to labor at home and assuming normal progress, to give birth there. Since this voluntary choice by the mother reduces the customary expense of hospital-based maternity care by a whopping 76%, one must wonder why your company is not strongly supportive of this choice .Your letter states that "Aetna US Healthcare does not cover home deliveries". This is somewhat confusing as, unlike hospital-based care, there is no charge to the insurance company when mothers give birth at home. I assume that you mean that Aetna does not reimburse the professional attendant for birth services provided in a domiciliary setting. This is an odd policy in an era highly concerned with reducing healthcare costs which has resulted in a mushrooming of home healthcare even for the most serious illnesses or post-op situations. It is curious that a profit-driven health insurance company would force healthy mothers enjoying normal pregnancies into the biologically hazardous environment of the acute care hospital while pushing for early release or home care for those who are seriously ill or recovering from major surgery.
Relative to hospital birth, home births offers lower rates of neonatal mortality and cesarean section . When healthy mothers are routinely hospitalized it needlessly exposes them and their neonates to a host of antibiotic resistant pathogens and many other nosocomial complications. It increases neonatal mortality and the rate of cesarean sections with all the potential complications subsequent to major surgery . According to data from the CDC, approximately 100,000 Americans die each year from nosocomial infections and complications of medical or surgical treatments. In addition to the personal tragedy to the family from these preventable deaths, surely this type of terminal care is expensive for the third-party payers such as Aetna US Healthcare. At the very least it is bad press for Aetna US Healthcare to be associated with forcing healthy mothers against their best judgement into this bio-hazardous environment that markedly increases the risk and economic cost through increased use of interventions such as induction of labor, administration of narcotics, epidural anesthesia, episiotomy, cesarean surgery, admission of the neonate to the NICU and to a lesser extent, increased neonatal mortality.
In a global economy the cost of maternity care cannot help but become a central issue, as 60% of mothers world-wide are attended by midwives and their babies born at home at a cost of a few hundred to a few thousands of dollars. The five countries with the best maternal-infant outcomes have 70% or more of the births attended by midwives. In the US childbirth makes up 1/5th of all healthcare expendures  and is the single mostfrequent cause for hospitalizations . Denial of access to home-based birth services by major health insurance companies not only denies this safe choice to the childbearing family but equally important, denies to society the economic benefits of this efficacious form of maternity services. This has a negative economic impact for the US by making American businesses less able to compete in the global market. The cost of products and services in the US must reflect the inflated costs of hospital delivery which on average (1998) were more $7,565 for a vaginal birth and nearly $12,000 for a Cesarean section. Approximately 20% of US birth are by Cesareans, which for low risk women is three times the rate of mothers planning to give birth at home.
CNM provided domiciliary care averages under $2,000.In one study of 11,788 women attended by CNM and intending to deliver at home, 8% were transferred to a hospital setting after onset of labor, 0.8% after delivery and 1% of neonates were hospitalized. The average cost of emergency transfer pro-rated was negligible ($9.60), The Cesarean rate for the nurse midwives was 3% while hospital rates ranged from 8.3 to 26.9%. There was no maternal mortality and the perinatal mortality (excluding congenital anomalies incompatible with life) was 0.9%. Hospital rates for the same category was 2%. [1, 4]
I can only assume these policy decisions reflect a misunderstanding of the literature regarding the efficacy of domiciliary maternity care by qualified attendants. I have enclosed excerpts of several peer-review articles documenting many points of interest to your company and its shareholders. I hope you will address my concerns and look forward to hearing from you soon in reply to this letter.
Faith Gibson, LM, CPM
cc:Dr Arnold Cohen, Director of Womens Health, Aetna US Healthcare
References1. The Cost-effectiveness of Home Birth, Rondi E. Anderson, CNM, MS, and David A Anderson, PhD; JNM, Vol 44, No 1, Jan/Feb 1999
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