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.

Samaritan Ministry Is Going To Kill Someone: Part 1

Years ago - back when I was teaching full time at a high school - I ran into Samaritan Ministries through a reference on one blog or another.   Samaritan is a member to member health insurance cost sharing plan for Christians who want emulate how the early Christians lived.  The basic idea is pretty simple: instead of sending a policy payment to an insurance company every month, members send their monthly payment to a member who has had a large medical bill.  The member uses that money to pay the providers and everyone is happy.

Back then, there was only the plan that is referred to as "Samaritan Classic" now.  Members had a $500 deductible on each medical issue then the rest of the cost of treatment could be reimbursed up to $250,000.  The plan has some exclusions around sexual health in that abortions, problems resultant from an abortion and STD testing were excluded from being funded.  At the time, my only concern was for women or men who had a spouse who had an affair and needed to get STD testing because of that; it felt like punishing the innocent spouse.  My gut assumption was that people who were attracted to Samaritan would not be seeking abortions for any reason.

Fast forward to last month when I got pulled into the rabbit hole again when researching something about the Maxwell Family businesses pulled up a blog post on how Samaritan Ministries covered the medical bills for Nathan Maxwell's daughters Susannah (who was born with terminal brain damage from unknown causes) and Abigail. 

As I was looking at their section on  "Maternity and Newborn Care", I saw three sections that scared me from a medical standpoint: ectopic pregnancies, home births and vaginal births after cesarian -sections (VBACs).  This post will cover ectopic pregnancies.

Ectopic Pregnancies:
An ectopic pregnancy is a pregnancy that implants anywhere outside of the uterus.  The most common site for ectopic pregnancies is the fallopian tube - but rarely it occurs on the ovary, the outside of the uterus, the intestines or the cervix.  Fallopian tube ectopic pregnancies will either end when the fetus dies from lack of blood supply or will end when the fallopian tube ruptures causing the fetus to bleed to death when the placenta detaches long before viability is reached.  The danger with a tubal rupture is that it can cause massive internal bleeding for the mother and often requires a more complicated surgery to stop the bleeding and mitigate the damage to the mother's reproductive system.  Women do die in developed nations from ectopic pregnancies but it is rare because doctors  treat ectopic pregnancies by chemical or surgical removal as soon as they are diagnosed.  In developing nations, the fatality rate of diagnosed ectopic pregnancies is around 3% - and is probably higher since women who die away from medical facilities would not be reported.

To be clear, NO pregnancies have survived to viability from a fallopian tube ectopic pregnancy.  A handful of ectopic pregnancies outside of the fallopian tube have surivied to viability - but the most common outcome is fetal death from lack of blood supply.  Delivery of an ectopic pregnancy outside of the fallopian tube is a life-threatening surgery for the mother; the placenta has infiltrated blood vessels of organs that do not have the muscular response to contract when the placenta is removed.  This can lead to catastrophic bleeding that has lead to maternal death - and can do so long before viabilty is reached.

 Samaritan's Policies:

Expenses Shared—Procedures related to a ruptured fallopian tube (including post-operative recovery of the mother, follow-up care, and treatment of any complications), and, where an ectopic pregnancy is diagnosed before a rupture, all pre-operative tests and consultations and expenses related to keeping the mother under medical care while determining what care should be offered for the mother and child.

  Expenses Not Shared—Procedures directly related to the termination of a living, unborn child and/or removal of the living, unborn child from the mother due to an ectopic pregnancy are not shared (e.g. methotrexate, salpingectomy, salpingostomy), unless the removal of the child from its ectopic location was for the primary purpose of saving the life of the child or improving the health of the child.

Issues: Samaritan is mandating that women choose the popular among QF Evangelical route of "Watchful Waiting" where women diagnosed with ectopic pregnancies wait until either the fallopian tube ruptures (or something similar if it is another organ) or the baby dies before removing the pregnancy.

This is a horrible idea based on flawed premises.  The rationale goes that women in the US and Europe have a really low rate of mortality from ectopic pregnancies so it's not dangerous for women to put off treatment of an ectopic pregnancy as long as they are being carefully monitored by their doctors.

The reason that developed nations have low rates of mortality is because doctors interviene in ectopic pregnancies prior to rupture - even if the fetus is still alive.  I'm Catholic and the Catholic Church has recognized this basic principle for as long as doctors have been able to diagnose ectopic pregnancies.  There is no chance of survivial for the fetus and ~25% chance of a potentially lethal rupture for the mother so the Church allows for the fallopian tube to be removed.  Yes, this kills the baby - but the purpose of the surgery is not to kill the baby but to prevent a ruptured tube so it is not immoral.  I find the rationale a bit hackneyed - but women have an option to end the pregnancy.

The QF believers will reply "But we don't really know how long a Fallopian pregnancy can survive because doctors won't let nature take its course!"

Here's a sane reply: Ectopic pregnancies have been killing women for centuries.  Doctors have been doing autopsies on dead women for 150 years.  They've collected plenty of data from dead women with dead babies that shows that ectopic pregnancies in the fallopian tubes will rupture by 16 weeks and that the later the rupture happens the higher chance of maternal mortality or injury. 

OB/GYNs like babies.  They like delivering healthy babies to healthy mamas.  They would love to figure out how to save ectopic pregnancies - but it's not possible until we can build a placenta from scratch and attach it in the right place.

There will be another post on this topic soon. :-)