This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. In this blog, we’ll look at the ninth “P” of my 10 “P’s” of keeping labor shorter and birth safer — payment.
Interestingly, if operative deliveries and cesareans can identify labor or delivery processes that are not normal, then the medical literature lists several payment mechanisms that may be associated with keeping normal labor normal.
First, is the capitation of maternity care services, as “…the probability for cesarean section is lower for an HMO delivery than for a fee-for-service delivery …”(79)
Not only does capitation, when it reaches a health care service area reduce the incidence of operative deliveries in the capitated systems, but “…  HMO and IPA penetration … have important effects on c-section rates, not only in HMO/IPA settings, but throughout an area.”(79)
In one California study, “…  successive lower rates (of c-sections) were observed for women covered by private insurance (29%), non-Kaiser HMOs (27%), Medi-Cal (23%), Kaiser (20%), self-pay (19%), indigent services (16%).”(80)
In addition, “VBACs occurred twice as frequently in women covered by Kaiser (20%) and indigent services (25%), compared to private insurance (8%).”(80)
Not only this, but the reasons for operative deliveries significantly chanted as “the associations between payment source and cesarean section use were also noted for the indications of breech presentation, dystocia, and fetal distress.”(80)
In addition, in this study, “Accounting for maternal age and race/ethnicity did not alter these findings.” (80)
A second payment mechanism that seems to reduce the prevalence of operative delivery is the provision of salaries for maternity care providers, as “… mothers with private, fee-for-service insurance have higher c-section rates than mothers who are covered by staff-model HMOs (where all the doctors are paid a salary), who are uninsured, or who are publicly insured.” (81)
A third payment option that seems to be associated with reduced operative deliveries is the same payment regardless of the type of delivery (vaginal, operative vaginal, or cesarean) or the type of care giver (midwife or physician): “… typically insurers pay at least 50% more for cesarean section than for vaginal deliveries … (and) … c-section rates were unrelated … to perinatal outcomes … (Therefore, and) … given these results, insurers should consider paying a flat fee for obstetric services unless differing risk levels or risk-adjusted outcomes justify different amounts.” (42)
One interesting commentary recently stated that “… the bottom line for managed care organizations tends to be cost of care. In other words, bad outcomes are no longer profitable … Because normal births without technical interventions tend to be relatively inexpensive, practices such as intermittent auscultation, avoidance of anesthesia, and a strong emphasis on labor support have a greater chance of acceptance. … Therefore, changes in health care financing, particularly managed care with capitation, may further support these changes.” (42)

Here’s the entire series:

• Introduction
• The Costs of Abnormal Labor
• THE 10 P’s

1. Philosophy,
2. Partners,
3. Professionals,
4. Pain control,
5. Procedures,
6. Patience,
7. Preparation,
8. Positions,
9. Payment, and
10. Prayer.

• Summary

Citations:
(42) Nesbitt TS. Rural maternity care: new models of access. Birth 1996;23:161-5.
(79) Stafford RS. Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health 1990;80:313-5.
(80) Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q 1993;71:365-404.
(81) Finkler MD, Wirtshcafer DD. Why pay extra for cesarean-section deliveries? Inquiry 1993;30:208-15.
(79) Stafford RS. Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health 1990;80:313-5.
(80) Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q 1993;71:365-404.
(81) Finkler MD, Wirtshcafer DD. Why pay extra for cesarean-section deliveries? Inquiry 1993;30:208-15.