The American College of Domiciliary Midwives
3889 Middlefield Road ** Palo Alto, CA 94303

March 4th 1999

Dr Jerry Frank, Senior Medical Director
Nassau Omni West, Suite 502
333 Earle Ovington Blvd
Uniondale, NY 11553

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 company’s 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 [1].

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 [1]. 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 [2]. 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 [2] and is the single most frequent cause for hospitalizations [3]. 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.

Warm Regards,

Faith Gibson, LM, CPM
Director, ACDM

cc:        Dr Arnold Cohen, Director of Womens Health, Aetna US Healthcare
              Corporate Offices, Aetna US Healthcare
              Citizens for Health -- national office and NY state director
              Citizens for Midwifery - national office
              American College of Nurse-Midwives -- national office --
              Coalition for the Improvement of Maternity Serivces - national office


1. The Cost-effectiveness of Home Birth, Rondi E. Anderson, CNM, MS, and David A Anderson, PhD; JNM, Vol 44, No 1, Jan/Feb 1999
2. Mushinski, M.;
Average charges for uncomplicated vaginal, cesarean and VBAC deliveries; regional variations, US, 1996 Stat Bull Metrop Insur Co 1998, Jul-sep: 17-28
3.Centers for Disease Control and Prevention. Trends in lengths of stay for hospital deliveries -- US, 1970-1992 MMWR 1995; 44:335-7
4. Anderson RE, Murphy PA,
Outcomes of 11,788 planned home birth attended by certified nurse-midwives. J Nurse Midwifery 1995; 40:438-92

Enclosured Documentation / Excerpts from:

1. "Cost Effectiveness of Home Birth" / JNM Jan/Feb 99; Selected Conclusion and Recomendations from the Winterton Report on Maternity Services by the House of Commons Health Committee
2. "
Effective care in pregnancy and childbirth a synopsis for guiding practice and reseach" -- Appendix 4 -- FOrms of care that should be abandoned in light of the available evidence, including Involving doctors in the care of all women during pregnancy, involving obstetricians in the care of all women during pregnancy, insisting on universal institutional confinement, etc
3. synopisis of "
Outcomes of Intended Home Birth in a NM Practice A Prospective Description Study" originally published in Obstetrics & Gynecology, Sept, 98
Fact Sheet: The Safety of Home Birth, published by Citizens for Midwifery with list of 24 citations

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