C-SECTIONS: STUDIES EXAMINE MEDICAID RATES, TRIALS OF LABOR

      Women receiving Medicaid in New York are "more prone to
 having complications when giving birth, but are less likely to
 undergo Cesarean sections," AP/BOSTON GLOBE reports.  A state-
 wide report released yesterday by Boston-based HealthShare
 Technology Inc. analyzed the 260,183 deliveries in the state in
 1994; 40% of the births were to Medicaid recipients (Bauder, 9/4)
 The report, "Healthcare for New Mothers," found "startling
 differences in health care in the areas of complicated delivery
 rates, lengths of hospital stay and charges" (HealthShare   
 release, 9/4). 
      FINDINGS:  The study found that one in five Medicaid mothers
 had C-sections, compared to 26% of women with other forms of
 insurance (AP/GLOBE, 9/4).  In addition, Medicaid recipients were
 35% more likely to experience complicated deliveries and averaged
 3.1 days in the hospital following birth compared to an average
 stay of 2.8 days for non-Medicaid mothers.  The study found that
 Medicaid births were more expensive than non-Medicaid births; the
 state-wide average charge was $4,118 for women on Medicaid versus
 $3,351 for women with other insurance.  According to HealthShare,
 the higher costs were due to higher complication rates and
 increased utilization of resources associated with complications
 (HealthShare release, 9/4).
      PAYMENT PLAN:  According to the state health department,
 "Medicaid's reimbursement for C-sections is lower than that for
 most private insurers."  HealthShare founder Richard Siegrist Jr.
 said that the study data should be used to question "how much
 economic factors are taken into account when medical decisions
 are made."  Kristine Smith, a spokesperson for the state health
 department, said that while economic factors are "one factor" in
 medical decisionmaking, "We do not believe that it is the only
 factor and that there are other factors equally at play here." 
 She noted that Medicaid recipients "tend to be younger than women
 with private insurance" and are more likely to delivery vaginally
 and less likely to request a C-section (AP/GLOBE, 9/4).
      TRIALS OF LABOR:  Women who try a vaginal birth after a C-
 section delivery (VBAC) are "almost twice as likely" to
 experience "major maternal complications" than those who choose a
 subsequent C-section, according to a new study in today's NEW
 ENGLAND JOURNAL OF MEDICINE (NEJM) (McMahon, 9/5 issue).  The
 study found that the risk of complications was 1.6% for whose
 women who attempted vaginal deliveries and 0.8% for those who
 underwent a C-section (Winslow, WALL STREET JOURNAL, 9/5). 
 However, USA TODAY notes that the study of 6,138 Canadian women
 found that for the most part, attempting a vaginal delivery is
 "very safe" and is successful 60% to 80% of the time.  According
 to the study's lead author, Dr. Michael McMahon of the University
 of North Carolina at Chapel Hill, the problem is that the failed
 attempts usually require emergency C-sections that follow long
 and difficult trials of labor (Painter, 9/5).  
      REDUCING THE NUMBERS:  Public efforts currently underway are
 attempting to reduce the number of C-sections performed in the
 U.S. from 25% to 15%   (JOURNAL, 9/5).  And NPR's Que notes that
 "increasingly, managed care companies are now requiring all women
 to first attempt a vaginal delivery -- even if they've had a
 Caesarean in the past."  But McMahon cautions that we "need to be
 careful that we don't mandate that women undergo a trail of
 labor" ("Morning Edition," 9/5).  But he also said that doctors
 who refuse to advise women to attempt a vaginal delivery
 following a C-section are "as guilty as managed care companies
 that mandate a trial of labor without giving women a choice"
 (JOURNAL, 9/5).  In a NEJM editorial in today's issue, University
 of Southern California's Dr. Richard Paul said repeat C-sections
 account for only one-third of all C-sections; the rest are first
 time deliveries.  As a result, he said, first-time C-sections are
 the ones insurers should be attempting to reduce (9/5 issue).