Why Are Elected C-Sections Are Covered But A Doula Isn't

The medical profession may well be on its way to making pregnancy and childbirth an exact science, precisely timed to within a quarter of an hour. The question is, will the insurance industry and US labor laws keep up? When a woman becomes pregnant, it is often said that her body is no longer her own. Modern pregnant women are not only at the mercy of hormonal changes, but are also subject to changing insurance policies and altering company medical leave guidelines as well. So, ironically, with the advent of medical intervention in births, women have surprisingly more and less options.

Julianne Johnson


Typical pregnancy

Let's take for example a basic, low risk pregnancy. As the mother's body goes through drastic changes, new medical needs and family concerns will arise. Invariably, there will be cracks in coverage or understanding between insurer and the insured.

Back pains and spasms, common in even the most perfect pregnancy, pose problems for women depending wholly on their insurance for help. Many insurance companies, like Oxford Health Insurance, for example, will not fully cover prenatal massage therapy. Maria Gordon Shydlo, director of public relations at Oxford says the company will recommend massage therapists with whom they have negotiated a member rate, or lower rate, but the "member does the research". All this means, it that is up to the Oxford group member to call around and find a massage therapist that specializes in prenatal massage. Our research indicated that few of the massage therapists listed on Oxford's website in one sample area code had experience in prenatal massage.

One licensed prenatal massage group contacted, not covered under Oxford, even suggested a bit of deception such as a member coming into their practice for a number of consecutive visits and simply calling it physical therapy instead of massage therapy to get the patient's insurance to cover it. If a pregnant woman was looking merely for a little short term pain relief this option would, in the end, cost her insurance much more then the simple prenatal massage. The cost effectiveness for Oxford or any other leading provider to cover the basics in this instance would seem apparent.

Preventative coverage
Preventative coverage seems to be an area in which most major insurance companies are lacking. There is a new concept developing in labor and delivery involving the use of a labor assistant or doula. Experienced birth partners have been around since the beginning of time, but the word "doula," which is Greek for "trusted servant" was actually coined back to the early 1990s. Unlike a nurse-midwife, who is a healthcare provider trained in both nursing and midwifery and certified by organizations like the American College of Nurse-Midwives, a doula is not a medical professional. Rather, a doula is a labor coach who can attain certification in her trade and assists during childbirth with everything from breathing and relaxation to breast feeding. There are also postpartum dowlas to assist in the early weeks following childbirth.

Doulas are not typically covered
While doulas are not medical professionals, many medical institutions have documented their success in natural childbirth. Allina Health Systems, a Minneapolis-based HMO and hospital network, did a 1996 study of six clinical trials. The results showed a 50 percent reduction in cesareans among mothers who used doulas, a 25 percent decrease in the length of labor, and a 30 percent drop in the use of pain medication. When Allina did its own trial, the results were even more striking. Mothers assigned doulas had 64 percent fewer cesareans, 38 percent fewer epidurals, and a 27 percent reduction in labor duration. Each avoided epidural reportedly saves nearly $200 and each c-section that is circumvented saves more then $4,000. This all translates to lower medical bills for insurance companies. Yet, still companies like Cigna do not cover doulas because, according to Amy Turkington, a spokeswoman for Cigna's, doulas, "do not meet the standards of a provider and are not credentialed."

Shydlo, at Oxford, says doulas have become "a topic of discussion" in their quest to provide more comprehensive coverage. However, neither Cigna nor Oxford covers the cost of a Lamaze class. Lamaze is a common method of breathing and relaxation that many pregnant women subscribe to while trying to achieve a natural or unmedicated birth. As is the case with doula assisted births, these unmedicated births are more cost effective then intervention procedures.

Choosing cesarean
Contrary to mothers in search of a natural, unmedicated birth, there seems to be a rise in "patient choice" cesarean sections. These c-sections are major surgeries where the doctor makes an incision in the woman's abdomen and uterus and removes the baby through it.

According to a new report released by Health Grades Inc., the healthcare quality company, from 1999 through 2001, the percent of "patient choice" c-sections, those for which there may be no medical indications, grew from 1.56 percent to 1.87 percent, a 20 percent rise.

"There is a clear trend of women choosing c-sections over vaginal births at an increasing rate, an issue that divides obstetricians," says Dr Samantha Collier, Health Grades' vice president of medical affairs. "Some obstetricians see c-section deliveries as a treatment choice and support giving women the right to choose a c-section delivery for reasons such as concern about future urinary incontinence and sexual dysfunction."

A pregnant woman may elect to have a scheduled cesarean section for personal wishes or for convenience. Often they are chosen to accommodate traveling, long distance relatives or even to afford the mother-to-be more predictability in her work environment. C-sections are generally 2.3 times more expensive than a vaginal delivery and require, by law, a longer hospital stay for mother and child. Still, major insurance companies seem to cover all cesareans, whether patient choice or medical necessity.

Hospital stays
In 1996 President Clinton signed the Newborns' and Mothers' Health Protection Act mandating that health insurance companies provide coverage for at least 48 hours of inpatient stay following vaginal deliveries and 96 hours of inpatient stay following a cesarean section. Yet, the use of the word "hours" here is misleading. On a standard hospital tour through one of New York's premiere institutions, mothers-to-be were instructed lightheartedly by the labor and delivery nurse to avoid giving birth close to midnight, as their insurance will consider a day's worth of hospital stay to start at midnight. So if you are unlucky enough to give birth at 11:55 pm, your first day in the hospital is really only equivalent to 5 minutes.

The American Academy of Pediatrics recommends that most mothers and newborns stay in a hospital for at least 48 hours following normal vaginal delivery. However, if there are complications with either mother or child, they can be discharged from the hospital separately, because of insurance coverage. Mothers who are planning to breastfeed, find this a particular worry, as accessibility to their infant is of utmost importance during the first few days of life.

Another maternal concern with motherhood approaching is how much time she will be able to afford to spend with her baby. The Family Medical Leave Act provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that group health benefits be maintained during that leave. But if your company has less then 50 employees or you have worked for this employer for less than a year, you may not be covered under FMLA.


According to a survey conducted by a United Nations agency, the US is one of six countries, worldwide, that does not guarantee thorough corporate or government compensation paid leave for women when they give birth. Some American employers provide short-term disability insurance that pays a benefit to women for the typical six-week recovery from pregnancy, eight weeks for a c-section. Some states also provide medical disability payment for women on maternity leave. Women may also accumulate vacation time and sick days to use all at once as a way to keep up their income during a leave.

However, retirement savings and Social Security benefits often suffer for women who bear children, owing to the lapse in their employment standings. Many companies require their employees to attain a minimum numbers of years served before they are entitled to private or matching retirement funds. Unpaid leave, therefore, does not generally apply toward these goals.

The fetus is often, and sadly, considered a parasite to the woman's body in that is takes what it needs to survive. To many women of child- bearing age, swimming their way through medical, corporate, and insurance policies can seem just as draining. PregnancyAndBaby.com

Tags: insurance

recommended for you