Philhealth is a government-owned corporation who takes charge of the medical insurance of the Filipino people. Individuals pay P100 per month to be able to avail of partial subsidy for their hospital admissions and operations.
Last August 5, 2011, the Philippine Health Insurance Corporation or Philhealth passed a circular to all health care providers, members and hospitals stating the new guidelines for certain surgical procedures.
Included in that circular is the new Caesarean Section Package.
The memo states: "Elective Caesarean sections (e.g. CS per patient request) including repeat cesarean sections performed without indication shall not be reimbursed by the Corporation."
This move seems to aim at lowering the incidence of unnecessary Caesarean sections and to attempt more vaginal deliveries after a Caesarean procedure.
This change was accepted with some resistance not only from patients but from their obstetricians, as well.
Sarah Lim, a mother of two who delivered by Caesarean section in her past two pregnancies says "Does this mean I have to go into labor for my third baby?"
She was very apprehensive at the thought of delivering via normal vaginal birth knowing that she has two CS scars on her uterus.
"I refuse to do a trial of labor on a pregnant woman whose previous CS was not done by me." Dr. Maybelle Cagayan of Asian Hospital cannot assure the safety of the mother if she does not even know the method of closure and repair done by the previous doctor.
Dr. Israel Francis A. Pargas, Senior Manager of Benefits Development and Research Department of Philhealth, explained: "Discussions were made and public hearings were done for the revisions ... of course not all are happy. We are continuously evaluating and monitoring and appropriate changes shall be done if necessary."
He further stated: "The intent of the policy really is to pay appropriate procedures following specific indications. Philhealth will provide for the reimbursement even if it is a repeat CS as long as there is an indication written by the physician. The problem is most of the diagnoses that we receive in our data show a relatively high CS rate but with no clear indication."
Being an insurance company responsible for the welfare of the Filipino people, Philhealth also makes it their duty to protect the patients from unwarranted and unnecessary surgeries.
It seems that there will be a trend towards more vaginal births after Caesarean section for cases with no strong indication for a repeat abdominal delivery.
However, vaginal birth after cesarean section or VBAC is not without risk. There was a large, multi-center report published in 2003 by Abel et.al. stating the incidence of rupture of the uterus while attempting a normal birth after a cesarean is as high as 1 in 200 VBAC cases.
Several issues have to be considered before the doctor and the patient can together decide on a VBAC. The following factors have been identified to increase the incidence of uterine rupture:
1. Previous CS was repaired using a single-layer uterine closure technique
2. More than one previous uterine scar (included are previous cesarean, myomectomy or other surgeries entailing injury to the uterine muscle layer)
3. Less than 24 months interval from the last Caesarean delivery
4. Maternal age greater than 30 years (this has something to do with the thinning out of the musculature of the uterus as the woman nears the age of menopause)
5. Maternal fever during the first 6 weeks immediately after the last Caesarean section (any infection during the healing period of the previous cesarean may mean a weaker scar)
Finally, if the Philhealth and all health care providers would sincerely want to lower the over-all CS rate in our country, the repeat CS should not be the target. It is too dangerous for the mother and the baby.
All efforts should be made not to perform the primary CS in the first place. All first deliveries should be given a full trial of labor and all methods have to be exhausted before resorting to that very first cut.