The malpractice insurance crisis is prompting a small number of professional liability insurers to institute strict standards for performing vaginal birth after cesarean section.
And an Oklahoma insurer last month has gone as far as excluding coverage for the procedure, citing a high number of claims associated with allegations of failure to perform a timely cesarean.
For its part, Northwest Physicians Mutual Insurance Company in Oregon still covers vaginal birth after cesarean section (VBAC), but it instituted a requirement in late 2003 that physicians and nurse-midwives who provide obstetric care must submit verification that the hospital where they practice is able to meet specific criteria. To continue to be covered to perform VBAC, physicians and the facilities in which they perform VBAC have to demonstrate that a physician capable of monitoring and performing an emergency cesarean delivery is present in the hospital or on the hospital's campus throughout active labor.
The insurer bases its certification on a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG), which recommends that a physician capable of monitoring labor and performing an emergency cesarean be “immediately available” throughout active labor.
“Given the associated risks and elective nature of performing this procedure, coverage for the performance of VBACs will only be offered under specific criteria,” William Gallagher, M.D., president and chair of Northwest Physicians Mutual, said in a letter to physicians.
For N. Michelle Sang, M.D., an ob.gyn. in Portland, Ore., who is insured through Northwest Physicians Mutual, this change means she and her colleagues are a lot more selective about providing VBAC.
Since she is affiliated with two hospitals, it's not practical to expect to be in one hospital for a patient's labor and delivery, she said. As a result, Dr. Sang and her colleagues in the practice have their patients sign a contract acknowledging that they might not be able to undergo VBAC.
“We tell our patients that we cannot guarantee a trial of labor if their physician is not available—regardless of the call schedule—or if there are multiple patients in labor at more than one hospital for our office,” Dr. Sang said.
Although some physicians in her group are offering VBAC to any patient who is a good candidate, most of them only offer VBAC to patients who have already had a successful VBAC.
For Northwest Physicians Mutual, the decision to require adherence to the ACOG practice bulletin was primarily a patient-safety issue, Dr. Gallagher said. The company's board had considered instituting a full exclusion of VBAC but decided against it. “We're not really in the business to tell doctors what they can do and can't do,” he said.
Northwest Physicians Mutual isn't the only company asking physicians to certify that they will follow the recommendations laid out in the ACOG bulletin.
ProAssurance, a professional liability insurer that operates in a number of southern states, has a similar policy that requires physicians to sign endorsements saying they will follow the ACOG recommendations.
The company recently phased in this policy in Georgia, Virginia, North Carolina, Texas, and Tennessee. The change in policy is part of the company's ongoing evaluation of medical liability, said Frank O'Neil, a spokesman for ProAssurance.
The Utah Medical Insurance Association has developed its own guidelines that physicians must adhere to as part of their policy. VBAC is subject to special guidelines, along with other high-risk obstetric procedures, because it is a huge area of litigation and loss around the country, said Steven L. Clark, M.D., a Salt Lake City-based perinatal advisor for the Utah Medical Insurance Association and medical director of perinatal medicine for the Hospital Corporation of America.
Physicians are covered to perform VBAC only if they follow certain conditions such as not using prostaglandin agents, performing continuous electronic fetal heart rate monitoring, being within 5 minutes of the operating room throughout the patient's labor, and providing informed consent to the patient. In addition, VBAC for twin gestations is prohibited.
Dr. Clark said his company's guidelines aren't particularly strict and are similar to requirements in place by hospitals. “Our view of this … that this is basically a tertiary hospital procedure,” he said.
In Oklahoma, the Physicians Liability Insurance Corp. (PLICO) has taken its policy a step further by excluding from its malpractice coverage all VBAC procedures except in the case of an emergency. The new policy went into effect on Jan. 1.
The decision was based on a number of factors, said PLICO President and CEO Carl Hook, M.D., including ACOG's practice bulletin on VBAC, which was issued in 1999 and revised last year, and statistics showing an increased risk of uterine rupture when women undergoing VBAC receive uterine muscle contraction medications to assist labor.