Presto! Change-o!

A recent article in U.S. News and World Report, titled “Rate of Unnecesary C-sections Far Lower than Thought“, discusses an article in January’s Obstetrics and Gynecology which finds that “the real rate of unnecessary C-sections is 4%.” Huh?

First, I don’t have the study, so I can only go by this article, which was brought to my attention by The Unnecessarean Blog. My first thought is, define “necessary.” It appears that the study looked at women who were planning a vaginal birth and ended up with their first Cesarean (whether this was the woman’s first baby or not, I can’t tell). Now, it says, “The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section.” So now, define “low risk.” How was their risk status determined? Would it not be determined by pre-labor factors known to her doctor and presumably herself? The article says that going on birth certificate data alone, 58.3% of these women had no risk factors for a C-section; but that based on hospital discharge data, nearly 90% had a risk factor listed. Ok, define “risk factor.” How is it that over 40% of “women who were considered at low risk for needing a C-section” actually had at least one risk factor for a C-section? Doesn’t having a risk factor move you from “low-risk” to moderate or high risk? Maybe not. Maybe you can have one risk factor for a C-section and still be considered low-risk, but that two or more risk factors bumps you out of “low” risk.

Besides, having a risk factor for a condition and having the condition are two widely different things. A man may “have risk factors” for a heart attack, but that doesn’t mean that he will definitely die from a heart attack if he is not hospitalized from now until he’s 80; nor does it mean that a bypass operation is necessary.

Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren’t completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate.

“Doctors don’t touch birth certificates,” said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. “The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue.”

Now here is an interesting factor — doctors rely on discharge data to get paid by the insurance companies. I used to work for a pharmacy, and I know some of the hoops we had to jump through to get a medication approved for a patient. A friend of mine also went through months and months of hassle trying to get her husband’s various treatments approved (or pre-approved) by the insurance company; and some of the rejections were because the pencil-pushers (at either the doctor’s office, hospital, insurance company, or anyone else involved in getting data from one person to another) wrote or typed the wrong code. As an example of a type of false rejection (which also happened to this same friend), her second son (who was named Andrew, obviously a masculine name) was entered as a “female” into the insurance company’s database; and then they refused to pay for his circumcision (this is years ago, when it was still covered by most insurance companies) because their insurance policy didn’t cover pregnancy-related expenses for dependent daughters. In other words, because of the mix-up, the insurance company people and/or computers considered that newborn Andrew had just given birth to her first child.

So, doctors and everyone else in the health-care field have to be careful about how they code things and how they enter data into the various computer systems because their livelihoods depend on it. Doctors who don’t get paid for attending C-sections won’t be very happy campers. It makes me wonder if they are, um, getting creative with women’s risk factors when it comes to hospital discharge data so that they will get paid. Insurance companies — like every other company — don’t like spending money, and especially don’t like spending it unnecessarily. I’ve previously blogged about a hypothetical future scenario in which doctors’ malpractice insurance won’t let them attend VBACs, so they force women to have “elective” C-sections; while women’s health insurance won’t let them have “elective” C-sections — what happens then? Does she have a medically unnecessary repeat C-section or a VBAC? If she has the surgery, and her insurance company won’t cover the surgery because it’s elective, will she have to pay the doctor out-of-pocket for her unnecessary surgery, or will he just “eat” the cost?

Is this scenario actually happening now? Are doctors “discovering” risk factors for women after the surgery so that they can be sure that they’ll be paid for the surgery?

Consider the following story, which actually happened to someone I know. A woman gave birth to her 4th child (planned hospital birth — she loves epidurals), and the doctor came in, ready to discharge her, and asked if she was ready to be home, and she replied quite honestly that she was rather enjoying the respite she had from the demands of being at home with her older children, and enjoyed being able to focus on the new baby. So, the doctor looked at the thermometer he had just taken her temperature with and said, “Hmm, it looks like your fever is a little high [it wasn’t — it was perfectly normal], so I think you should stay in the hospital an extra day, just to be on the safe side — to make sure you aren’t getting an infection.” Presto, change-o, she suddenly “qualified” for an extra day of R&R in the hospital, courtesy of her insurance company. Think this doesn’t happen every day in every hospital in the country?

This study presumes that hospital discharge data is accurate, while birth-certificate data is deficient. It may be. I certainly have read numerous things (studies, mentions in other studies, articles that talked about studies) that have shown that birth-certificate data is not very reliable when making certain judgments. But to go from “nearly 60% of women have no risk factors” to “just less than 4% of women have no risk factors”?? At what point do you start questioning the hospital discharge data’s accuracy? Especially when doctors have a monetary interest in making sure they and the hospitals get paid for everything that was done, so that they don’t lose any money.

I remember a joke Abraham Lincoln was reported as telling: How many legs does a dog have, if you call its tail a leg? Four — calling a tail a leg doesn’t make it one!

In a similar way, suddenly discovering (after the birth) that a woman is obese, or has high blood pressure (you remember — that one time in that prenatal visit when her bp spiked?), or gained too much weight (we know how women lie about their weight), or had protein in her urine, or had edema, or had a headache (we’ll just forget it was because she knocked her head on the car door), or had a small pelvis (let’s just erase the previous “adequate pelvis” notation in her chart), or whatever the “risk factors” were that the doctors charted in order to get paid by the insurance company, doesn’t make them real.

Did the researchers take a cross-section sampling of these women to find out if the discharge data was accurate, or was it just assumed to be so? In the Johnson & Daviss CPM home-birth study published in the British Medical Journal, they said that in addition to the data gathering from the midwives and the birth certificates, that they took a sampling from the mothers and had them verify the details of what they had been told about the births, to make sure that there weren’t any errors. Was something like this done here? It might be interesting what women remember being told before the birth, and what they found out afterwards — like the woman who had a C-section for breech, only to find out that the baby had flipped sometime between the last ultrasound and the surgery, so she could have had a vaginal birth… but then the doctor came in and tried to justify the C-section by saying that “the baby was big [8 lb. something] and your pelvis was small [although it was previously noted to be the best pelvis shape], so you likely would have ended up with a C-section anyway.” That was bull. The parents didn’t buy it (but what could they do?); yet the doctor still got paid for his “necessary” C-section.


Between a Rock and a Hard Place

This is a prediction, not a fact, so I could be totally off-base here, but bear with me. It’s possible that some women have already had to face this.

In 5-10 years, women will be caught between battling insurance companies over elective C-sections and elective repeat C-sections.

Insurance companies, like every other company in a free-market society only survive when they bring in more money than they spend. This is true of grocery stores, convenience stores, department stores, and every other company from the local mom-and-pop to the giant Microsoft.

Health insurers charge a certain amount of money per month from their customers, based on actuarial tables of how costly their health care will be. This is why they do not want to accept clients with pre-existing conditions — they know up-front that these people will be more expensive than average. If they do have to spend more than the average on these or any other person, premiums go up and benefits go down. That’s life. Insurance companies don’t exist as a hobby or a charitable organization. They, like every other company in this country, exist to make money. And that’s not a bad thing.

Malpractice insurers do the same thing, but from the opposite perspective. They charge their doctor-clients a set amount, also based on actuarial tables, and how expensive a claim against their client will be for them. Obstetrics has one of the highest malpractice premiums of any class of doctors, and this is quite simply because sometimes birth doesn’t go as everyone wants, and some babies get damaged; and when a baby gets damaged, parents sue, and doctors settle; if they try to fight it, a sympathetic jury will see the damaged baby and stick it to the doctor and insurance company — even if the doctor did nothing wrong. In today’s society, there is no excuse for a less-than-perfect baby. So, doctors perform C-sections way too often, as a sort of “get out of court free” card. It’s hard to justify to a jury (especially a non-medical jury that often has no clue about the ins and outs of obstetrics and surgery) that a C-section wasn’t necessary when a baby ended up dead or damaged. It’s much easier to do 1000 unnecessary C-sections, and then be able to say, “Hey, I did everything I could, and it still didn’t turn out right, but it wasn’t my fault!”

But what happens after a C-section? This is truly where women will be squeezed between a rock and a hard place.

If a woman has another baby after having had a C-section, she will have to choose whether to have an elective repeat C-section or attempt a vaginal birth (unless she has placenta previa or some other condition which makes a C-section medically necessary). I foresee that health insurance companies are going to start balking at paying for elective C-sections, just as they already refuse to pay for other elective surgeries, like breast augmentation. After all, if surgery is not necessary, and a cheaper, natural alternative exists, why pay for the artificial and expensive way?

But doctors are refusing to attend VBACs — not because the evidence shows them to be riskier than any other pregnancy necessarily — the rate of uterine rupture and subsequent emergency surgery in attempted VBACs is about the same as the rate of other catastrophic things happening in an average woman, like umbilical cord compression or cord prolapse — but rather because their malpractice insurance companies are dictating to the doctors that they will not insure them if they attend VBACs. I’m assuming that the idea is that although the overall risk of uterine rupture in an attempted VBAC is very small, it is a known risk, and if it happens, the plaintiff’s lawyers can argue that the doctor was somehow at fault. If, however, cord prolapse happens, then the doctor’s defense is more easily made — “it was just one of those things that happened; it was unknowable beforehand, and we did everything we could to prevent a bad outcome.”

With 30% of American women giving birth by C-section for the most recent statistics, that number is likely to rise as the rate of VBACs fall. I’ve read of a hospital being built in Michigan, scheduled to open in another few years, I think, which is being built with many more operating rooms in the L&D floor, in anticipation of a 50% C-section rate. At the time I first read it, I thought that was laughable; now I’m not so sure. Even if it’s not 50% nationally, some hospitals or areas are already at that rate. The number of women having their first C-section keeps going up; and if they are not allowed to have vaginal births afterwards, then repeat C-sections will also increase.

So, what will these women do, when their doctors insist on an “elective” repeat C-section, but their insurance companies refuse to pay for it?

C-sections and insurance

I posted a recent press release about how that some women are being denied insurance coverage after having a C-section, unless they can show that they are infertile or have become sterilized. I want to discuss this some more.

Please note that I am not defending any insurance company’s actions — just talking about it.

In America, health insurance companies are for-profit companies, just like Wal-Mart, Burger King, and Radio Shack. If they cease to make a profit, they cease to exist. Just for kicks, I got an instant quote for an individual of my age from my state’s Blue Cross / Blue Shield, and found that (depending on which of the 2 plans were offered), maternity insurance would cost about $300 per month, if I had a $1000 deductible. [This is in addition to the approximately $200 per month for regular health insurance.)

A year ago, a friend of mine had an uncomplicated C-section due to the baby’s transverse lie (baby was positioned sideways in relation to her abdomen, instead of head-down which is the norm). The total hospital charge (not counting the doctor’s fees) was $25,000, of which my friend had to pay 20% or $5,000. That meant that the insurance company had to pick up the $20,000 tab. (Of course, most insurance companies usually have bargained with the hospitals and care providers for a certain maximum charge, so they may not have actually had to pay all of that, but for the sake of argument, let’s say that they did.) Now, $25,000 seems high for an uncomplicated C-section, and undoubtedly rates would vary based on the hospital, length of stay (my friend stayed less than 48 hours), if there were any infection or other complications, etc. But these are the figures I have to go with (if anybody wants to chime in with other known figures, please feel free to leave a comment — it will be interesting to see how much births cost in various parts of the country).

So, the insurance company had to pay $20,000. Although my friend said she just wouldn’t have any more children if she knew she’d have to have a C-section, let’s say that something happens in a future pregnancy and she does need a C-section (or can’t find a doctor or hospital that will allow VBACs). Assuming the same figures, the insurance company will have to fork over another $20,000. Then, let’s say that 5 years down the line, she has another baby by C-section. Now, the cost of the 3 C-sections to the insurance company is $60,000. While most people get health insurance through group coverage and get reduced premiums, let’s say that the cost of maternity insurance is $300 per month, which is what I figured. At this point, my friend would have paid $300/mo for 7 years for just her maternity coverage, or approximately $25,000 total. Then, she would also have to pay $5,000 per birth, or $15,000 out-of-pocket. [Remember, this is just for the hospital part of the birth — any doctor’s fees for the birth, or any prenatal visits are not included in this!] The cost to the insurance company, meanwhile, would be $60,000. They’d be $35,000 in the hole.

Remember, if the insurance company can’t make a profit, there’s no reason for them to exist — they are not a nonprofit organization. And if they can’t break even, they can’t survive. They can absorb the extra $35,000 for my friend, but what about for the other 30% of women who give birth via C-section every year?

In discussions I’ve had on my various birth-y email lists (childbirth educators, doulas, midwives, home-birthing women), we’ve often discussed this problem, and wondered aloud why insurance companies cover elective C-sections, but often don’t cover home births. My first midwife (a CNM in Illinois), said that insurance companies don’t cover home births for two reasons — the main one is that the people who sit on their boards to decide what they will and will not cover are doctors, and it’s sort of the “old boys’ club” and they just don’t like home birth so will not cover it. [As an aside, when Viagra was first available, I was working at a pharmacy, and was surprised to find that insurance companies covered Viagra. However, many of them did not cover birth control pills, because they said they were elective. I kid you not.] And a secondary reason is that if a woman plans a home birth with a midwife, and ends up transferring to the hospital (most midwives have about a 10% transfer rate for all reasons), then the insurance company may end up having to double-bill for the birth — one bill for the midwife for her prenatal care and labor care, and another bill for the hospital and doctors where the birth actually took place.

This blog had an interesting take on what to do — instead of legislation, or lobbying, or reaching women with the idea of homebirth, go to the Human Resources department of companies, and pitch covering homebirth and midwifery as being cost-effective and preventive care. [The author of the blog is also the author of The Ties that Bind, which is one of my favorite articles about birth.]

Let’s run some numbers. [Yes, I’m a nerd that way — if you don’t like numbers, you can skip to the end. :-)]

The US annual birth rate is approximately 4 million births per year, and planned home births comprise about 1% of that, or 40,000 births. I think the average cost of a home birth, with all the prenatal care and the one-on-one attention of a midwife throughout the whole labor comes to about $3,000 (which is about what it was for each of my two births). But let’s say that I’ve underestimated it, or we need to throw in some extra tests or ultrasounds or something, so we’ll “high-ball” it at $4,000 average across the nation. Since there is an average of 10% transfer rate to the hospital for any and every reason, 36,000 planned home births will be accomplished at home, while 4,000 will transfer to the hospital. Those 36,000 home births will cost $144 million. Let’s say that the average vaginal birth at a hospital costs $10,000 (and this includes all the prenatal visits and any doctor’s fees, so that figure is probably a bit low). Of the 4,000 women who transfer to the hospital, let’s say that half of them end up with a Cesarean (which is 5% of the total home-birthing group), while the other half go on to have a vaginal birth. That means that the 2,000 vaginal births will cost $20 million (paying the midwife’s prenatal fees but the doctor’s birth fee and the hospital charges out of that $10,000), while the 2,000 C-sections will cost $25,000 apiece or $50 million. So, the total cost of the 40,000 planned home births ends up being $214 million.

Now, let’s say these same women planned hospital births. While the current average C-section rate is 30%, about a third of those are planned repeat C-sections. Slightly less than a third of C-sections are due to “non-progressive labor,” while the remainder are for all other factors including fetal distress, breech or transverse position of the baby, maternal health factors, etc. I don’t know how many women have planned home VBACs (a.k.a. HBACs), so let’s just pretend that none of the 40,000 women fall into that category. Since women who plan to give birth at home are usually “low-risk” (no twins, triplets, etc.; no major health problems; no known placenta previa, etc.), we’ll also remove the 14% of C-sections that might occur for these reasons. So, we’ll say that 15% of these 40,000 women will statistically have a C-section in the hospital (which also coincides with the Listening to Mothers Survey, which found that half of the C-sections performed were unplanned). This means that 6,000 women will have a C-section, while 34,000 will have a vaginal birth. So, the cost of the C-sections will total $150 million, and the vaginal births will total $340 million, for a grand total of $490 million in the hospital.

Now, nationwide (assuming uncomplicated births, which is obviously not the case — we save a tremendous number of premature babies, and a large number of these are born by C-section), if 70% of the 4 million women have vaginal births that cost $10,000 apiece, and 30% of women have Cesareans at $25,000 apiece, we’re talking $58 billion per year that is spent on hospital births alone. Although not all women would want a home birth, and some women would be “risked out” of a home birth, let’s say that a third of American women could and would give birth at home (which is similar to the rate in the Netherlands), if they had the proper support, and if insurance covered it, etc. Assuming 30% instead of 1% home birth population (with the 10% transfer rate, and 5% C-section rate), it would save $11 billion per year in health-care costs.

Now, all those above figures are the total cost of the birth, as if paid by one entity. There are so many different types of insurance that it would be impractical to run numbers for all of them, but let’s say that the average person has to pay 20% of the copay for a birth (which is fairly common, at least in my area). Currently, many people who choose home births have to pay the entire amount out of pocket (although some insurance companies will cover home birth just like they would an obstetrician and hospital birth, while others will make the woman pay up-front and then reimburse her… or not). In my case, the cost of the total package of midwifery care and home birth ended up being less than my friend’s 20% of her C-section. If she had had a typical vaginal birth at a hospital, her out-of-pocket expenses would have been $2,000, which was about a third less than what my births cost. So, if consumers had to pay only 20% of $4,000 for a midwife-attended home birth, their portion would be $800, while the insurance company would pick up the remaining $3200. Running the numbers again, if insurance companies paid 80% of the 40,000/year planned home-birth costs, their expenses would be $171 million. If, because insurance companies don’t cover home birth, these 40,000 women go to the hospital, the insurance company will have to pay 80% of $490 million, or $392 million — more than twice what they would have to pay to cover home birth, even at a 10% transfer rate and having to pay a midwife, doctor, and hospital.

When will the insurance companies wake up? Right now, they seem to be beginning to, but some are doing it by refusing to cover women who have had a C-section. Doesn’t that strike you as “shutting the barn door after the cows have escaped”? But here it gets tricky — some C-sections are (or become) necessary. I don’t want doctors to refuse to do a necessary C-section because of the possibility that a faceless, soul-less insurance company might come behind him and deem it actually unnecessary and refuse to pay him. But I am all for reducing the C-section rate to a reasonable level. And if pressure from insurance companies helps, then I’m glad for that. Think about it this way — insurance companies tend not to pay for elective surgeries (cosmetic surgery, for example), so why should they pay for this one elective surgery? I think a better option for insurance companies to avoid the high costs of repeat C-sections is to avoid the initial C-section to begin with. They can start by refusing to cover elective C-sections, instead of not covering women who have already had C-sections. In a previous post, I ran some other numbers which seemed to indicate that the number of C-sections could easily be cut in half (mostly by doctors not practicing “defensive medicine” — waiting on nature instead of diagnosing “labor dystocia”, allowing VBACs, allowing some breech births — just in general not being so quick to cut women open). If the C-section rate were cut in half (even if all births continued to be at the hospital), the cost of birth would decrease by three billion dollars per year. That’s a lot of money!

Going back to a previous point — if insurance companies are forced to pay for unnecessary C-sections and repeat C-sections, then the cost of health insurance will go up. It has to. At $300/mo, it will take the insurance company about 5.5 years to recoup the cost of 1 C-section. In this time of changing companies and jobs and insurance providers, how many insurance companies are going to bet that after they’ve paid $20,000 for a C-section, the woman will continue to stay with their insurance and pay the maternity premium for 5&1/2 years, without having another baby (by C-section or not)? And every repeat C-section adds an addition $20,000 and an additional 5&1/2 years to recoup the cost. Certainly, there are a lot of women who have maternity coverage and do not use it — that’s how insurance companies operate and make money — they’re betting that you’ll pay in more than they pay out. But they understand the formulas, and they crunch the numbers, and they know how much they have to take in, in order to be profitable. With the rising rates of C-sections, and the falling VBAC rates, insurance companies are faced with two choices in order to stay in business — raise rates, or refuse to cover risky people. It’s the same way it’s always been. It’s just now that it’s hitting women who have few options when it comes to birth after Cesarean.

Another reason to avoid a C-section

Insurance Companies Rejecting Women with History of Cesarean

Some Companies Require Surgical Sterilization for Coverage;

Trend Gives New Imperative to Learn Ways to Avoid Unnecessary Cesarean

Redondo Beach, CA, June 1, 2008 – As reported in today’s New York Times, ICAN has begun tracking an alarming new trend of insurance companies refusing to provide health insurance for women with a history of cesarean surgery. In some cases, women are being rejected for coverage outright and in other case they are being charged significantly higher rates to obtain the same coverage as women without a history of cesarean. With over a million women each year undergoing this surgery, this practice has the potential to render large numbers of women uninsurable.

This trend surfaces as the rate of cesarean surgery, including unnecessary cesareans, continues to rise. In 1970, the cesarean rate was 5%. In 2007, it was 30.1%. Experts often cite the incentives within the health care system for driving up the rate of cesarean unnecessarily, including physicians’ medical malpractice fears, better reimbursement for surgery, and lifestyle conveniences for care providers and staffing efficiencies in having more “9-5” deliveries.

“Women are caught in the middle of a dysfunctional system. Doctors are telling them they need surgery, even when they don’t, and insurance companies, who are tired of paying the bill for so many frivolous surgeries, are punishing women for the poor medical care of doctors,” said Pam Udy, President of the International Cesarean Awareness Network (ICAN).

The trend is highlighted in the cases of women like Peggy Robertson of Colorado. When she applied for health insurance coverage with Golden Rule, her husband and her children were accepted, but her application was denied. After multiple inquiries directed to the insurance company, she was finally told that she was denied because she had delivered one of her children by cesarean. “It was shocking. I assumed that as a woman in good health I would be readily accepted,” said Robertson. “When I finally found someone who would explain why my application was denied, they had the audacity to ask me if I had been sterilized, stating that this was the only way I could get insurance coverage with them.”

As the incidence of cesarean increases, the evidence of the downstream medical complications for women and babies, and the associated medical costs, becomes increasingly apparent. Risks of cesarean in later pregnancies include increased incidence of infertility, miscarriage, fetal deformities, overgrowth of scar tissue leading to bowel problems, and potentially deadly placental abnormalities in subsequent pregnancies.

And though most women with a prior cesarean are being encouraged and often coerced into having repeat cesareans by their doctors and hospitals that have banned vaginal birth after cesarean (VBAC), a pair of recent studies done by the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network demonstrates that women who deliver vaginally after a cesarean fare significantly better than women who deliver by repeat cesarean. (Obstetrics & Gynecology 2008;111:285-291, Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery, Mercer et al, and Obstetrics & Gynecology 2006;107:1226-1232 Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries, Silver et al.)

“Most women are looking to avoid cesareans. But physicians often make surgery difficult to avoid by insisting on non-evidence based practices,” said Udy. Practices that fail to improve the outcomes for mothers and babies and increase the risk of cesarean section include inducing for going post-dates, inducing for suspected large baby, requiring fasting during labor, requiring women to be confined to bed for continuous fetal monitoring, and failing to offer continuous support to a mother in labor. “These care practices serve the system well, but not mothers and babies” Udy added.

In fact, women and their babies may be paying a higher price than being denied health insurance. Last August, the Centers for Disease Control reported that, for the first time in decades, the number of women dying in childbirth has increased. Experts note that the increase may be due to better reporting of deaths but that it coincides with dramatically increased use of cesarean. The latest national data on infant mortality rates in the United States also show an increase in 2005 and no improvement since 2000. Internationally, the U.S. ranks 41st in maternal deaths and has the second worst newborn death rate among industrialized nations.

Women who are seeking information about how to avoid a cesarean, have a VBAC, or are recovering from a cesarean can visit for more information. In addition to more than 90 local chapters nationwide, the group hosts an active on-line discussion group that serves as a resource for mothers.

Women who want to reach their lawmakers can visit Women who want to reach their state insurance commissioner can visit .

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

Contact: Gretchen Humphries (734) 323-8220