Samaritan Ministries is Going to Kill Someone - Part Two

In the first post in this series, I discussed the scary requirement that women who have ectopic pregnancies while on Samaritan Minstries health-care cost-sharing plan undergo "watchful waiting" and forego removal of the pregnancy until either the fallopian tube ruptures or the baby's heartbeat stops.   This is extremely dangerous for the mother because a ruptured fallopian tube can cause massive internal bleeding - and makes no difference in the outcome for the baby because the longest a pregnancy can survive in a fallopian tube before a rupture is 16 weeks which is two months prior to viability.

There are two other items in the "Maternity and Newborn Care" section of Samaritan Ministries that give me pause - and I need to give some background on how coverage works to explain my concerns.

Samaritan Ministries has two levels of cost-sharing coverage available.  The cheaper version is called "Samaritan Basic".  In return for a lower monthly cost-share amount, families have an inital deductible of $1,5000 for each medical issue that they need to cover (or have discounted by the doctor) before needs can be shared.  Once that basic benchmark is reached, 90% of the remaining cost is covered.  The older version is still available as "Samaritan Basic" and for ~$200 more a month, families receive a lower deductible of $300 a month and 100% of the remaining need is covered.

Here are the two sections that concern me:

Home Births—Home births have the $300 Samaritan Classic and $1,500 Samaritan Basic initial unshareable amount waived, and are not subject to prorating (see Section VI.D) because they reduce overall maternity costs.

After Cesarean—The $300/$1,500 initial unshareable amount is waived for a vaginal birth after cesarean (VBAC).

I have grave concerns about the morality of offering women a monetary reward in exchanged for increased risk during labor and delivery.

I believe that home births should be legal - but I also believe that women should be informed of the much higher rates of injury and death for both the infant and mother in the rare case that a condition or situation occurs where rapid, trained medical care is needed.  The vast majority of home births will end with a healthy baby and a healthy mother because statistically most births are uncomplicated.  The tricky bit is that there is no way to screen pregnant women perfectly to determine who will be able to deliver at home safely and who will have a delivery complication prior to delivery. 

 Within the CP/QF community, Jill (Duggar) Dilard and Jessa (Duggar) Seewald have attempted four home births - and ended up hospitalized after three of them.

Jill had her water break with Israel and was in labor for 48 hours at home before going to the hospital.  (Laboring for 48 hours after membranes have ruptured without medical care is a bad idea;  the longer the membranes have been ruptured the higher the risk of an infection beginning that could have bad outcomes for Israel.)  At the hospital, Jill and Derick were surprised to find out that Israel was in a breech position that could not be delivered vaginally.  Jill had an uncomplicated C-section with Israel.

Jessa's labor with Spurgeon was straightforward if extremely painful.  The baby was delivered without any problems, but Jessa lost a lot of blood when the placenta was being delivered.  Her blood loss was severe enough that she had to be transfered to a local hospital for treatment.  Thankfully, she didn't have any retained placenta pieces and the bleeding stopped easily.  Now, the Duggar spin is that the blood transfusion she received the next day was simply a precaution because she was really tired after birth - but blood transfusions are never a standard occurance after giving birth.   By comparison, I came into the hospital with poor blood volume due to HELLP syndrome when my son was born, bled fairly little during his C-section and never needed a transfusion.  Don't get me wrong; I felt like shit-warmed-over for the first week after his birth and needed wheelchair transportation if I was going farther than a few hundred feet - but Jessa Seewald was worse off than I was.

From my point of view, telling pregnant women that they should giving birth away from trained medical professionals, pain relief, antibiotics, blood transfusions, operating rooms and emergency support for their newborn to save money is absolutely sick.

There's a question I have as well - will Samaritan cover the entire medical cost of a home birth gone wrong without proration, deductibles or maximum?   As nasty as home birth side-effects can be for mothers, the side-effects for babies can be catastrophic.  When a baby is born after oxygen deprivation or meconium inhalation, the medical treatments add up fast: three days of full-body cooling with 1:1 or 2:1 nurse to baby supervison, oxygen support through a ventilator, CPAP, or ECMO, neurological testing, blood work, dealing with feeding issues... a baby can rack up $10,000-$50,000 in charges per day.  Don't forget:  Samaritan - unlike commerical health insurance or  Medicare  - doesn't cover durable medical equipment once the kid is discharged.  My son went home on a medical-grade monitor and oxygen from a concentrator.  Those are rented at $300 per month each.  That doesn't include the disposable items he needed like nasal cannulas, NG tubes, specialized tapes to stick both to his face.    Samaritan does cover 45 days of home nursing care - which won't last long a baby goes home on a ventilator. 

The second issue surrounds vaginal births after C-sections which is shortened to VBACs.   VBACs carry a higher risk of side-effects to both the mother and infant.  The most concerning issue is that the scar from the previous C-section will rupture.  To qualify for a VBAC, women need to have a scar that is entirely contained in the lower section of the uterus.  These type of scars have a 1% chance of rupture during a VBAC so women who want to attempt a VBAC need to do so in a hospital where the baby can be monitored and an emergency C-section can be done if a rupture occurs.  A uterine rupture carries a higher risk of postpartum bleeding leading to a transfusion or an emergency hysterectomy.  Very rarely, the baby suffers injury or death from oxygen deprivation between when the rupture occurs and when the baby can be delivered by C-section despite being in the hospital.

I would hate for a woman to feel compelled to try a VBAC for finanical reasons; that seems cruel to risk serious complications because a family badly needs money for other things. 

My largest concern is for women who decide to try a VBAC at home.   Having a VBAC in the hospital mitigates the risks of bleeding and rupture by having an operating room and mass blood tranfusion protocol immediately available if the baby shows signs of distress.   Havign a VBAC at home raises the risk factor exponentially.  First - not all women who have had a C-section are good candidates for a VBAC.  Because my son was born very early, I have a scar that reaches into the upper section of the uterus.  These types of scars have between a 6-12% chance of rupture during labor.  Spacing between babies is also important for VBAC candidates; a pregnancy conceived earlier than 18 months-2 years after a C-section more likely to have a uterine rupture because the scar didn't have time to fully heal before being stressed by the next pregnancies.  Since home birth attendants are almost never OB/GYNs or CNMs in the US, mothers who are being cared for by non-medical professionals prior to a home birth may not be screened appropriately.  Second - if a rupture or catastrophic bleeding occurs, precious time is wasted in transporting the mother to a hospital, getting her stabilized and starting a C-section.   This can directly lead to the death of the baby or the mother.