Midwives Deliver
From the Los Angeles Times Opinion
by Jennifer Block
December 24, 2008
Some healthcare trivia: In the United States, what is the No. 1 reason people
are admitted to the hospital? Not diabetes, not heart attack, not stroke. The
answer is something that isn't even a disease: childbirth.
Not only is childbirth the most common reason for a hospital stay -- more than 4
million American women give birth each year -- it costs the country far more
than any other health condition. Six of the 15 most frequent hospital procedures
billed to private insurers and Medicaid are maternity-related. The nation's
maternity bill totaled $86 billion in 2006, nearly half of which was picked up
by taxpayers.
But cost hasn't translated into quality. We spend more than double per capita on
childbirth than other industrialized countries, yet our rates of pre-term birth,
newborn death and maternal death rank us dismally in comparison. Last month, the
March of Dimes gave the country a "D" on its prematurity report card;
California got a "C," but 18 other states and the District of
Columbia, where 15.9% of babies are born too early, failed entirely.
The U.S. ranks 41st among industrialized nations in maternal mortality. And
there are unconscionable racial disparities: African American mothers are three
times more likely to die in childbirth than white mothers.
In short, we are overspending and under-serving women and families. If the
United States is serious about health reform, we need to begin, well, at the
beginning.
The problem is not access to care; it is the care itself. As a new joint report
by the Milbank Memorial Fund, the Reforming States Group and Childbirth
Connection makes clear, American maternity wards are not following
evidence-based best practices. They are inducing and speeding up far too many
labors and reaching too quickly for the scalpel: Nearly one-third of births are
now by caesarean section, more than twice what the World Health Organization has
documented is a safe rate. In fact, the report found that the most common
billable maternity procedures -- continuous electronic fetal monitoring, for
instance -- have no clear benefit when used routinely.
The most cost-effective, health-promoting maternity care for normal, healthy
women is midwife led and out of hospital. Hospitals charge from $7,000 to
$16,000, depending on the type and complexity of the birth. The average
birth-center fee is only $1,600 because high-tech medical intervention is rarely
applied and stays are shorter. This model of care is not just cheaper; decades
of medical research show that it's better. Mother and baby are more likely to
have a normal, vaginal birth; less likely to experience trauma, such as a bad
vaginal tear or a surgical delivery; and more likely to breast feed. In other
words, less is actually more.
The Obama administration could save the country billions by overhauling the
American way of birth.
Consider Washington, where a state review of licensed midwives (just 100 in
practice) found that they saved the state an estimated $2.7 million over two
years. One reason for the savings is that midwives prevent costly caesarean
surgeries: 11.9% of midwifery patients in Wash- ington ended up with C-sections,
compared with 24% of low-risk women in traditional obstetric care.
Currently, just 1% of women nationwide get midwife-led care outside a hospital
setting. Imagine the savings if that number jumped to 10% or even 30%. Imagine
if hospitals started promoting best practices: giving women one-on-one,
continuous support, promoting movement and water immersion for pain relief, and
reducing the use of labor stimulants and labor induction. The C-section rate
would plummet, as would related infections, hemorrhages, neonatal intensive care
admissions and deaths. And the country could save some serious cash. The joint
Milbank report conservatively estimates savings of $2.5 billion a year if the
caesarean rate were brought down to 15%.
To be frank, the U.S. maternity care system needs to be turned upside down.
Midwives should be caring for the majority of pregnant women, and physicians
should continue to handle high-risk cases, complications and emergencies. This
is the division of labor, so to speak, that you find in the countries that spend
less but get more.
In those countries, a persistent public health concern is a midwife shortage. In
the U.S., we don't have similar regard for midwives or their model of care.
Hospitals frequently shut down nurse-midwifery practices because they don't
bring in enough revenue. And although certified nurse midwives are eligible
providers under federal Medicaid law and mandated for reimbursement, certified
professional midwives -- who are trained in out-of-hospital birth care -- are
not. In several state legislatures, they are fighting simply to be licensed,
legal healthcare providers. (Californians are lucky -- certified professional
midwives are licensed, and Medi-Cal covers out-of-hospital birth.)
Barack Obama could be, among so many other firsts, the first birth-friendly
president. How about a Midwife Corps to recruit and train the thousands of new
midwives we'll need? How about federal funding to create hundreds of new birth
centers? How about an ad campaign to educate women about optimal birth?
America needs better birth care, and midwives can deliver it.
Jennifer Block is the author of "Pushed: The Painful Truth About Childbirth
and Modern Maternity Care." She has been a journalist for nine years,
writing and editing for magazines and newsweeklies, frequently covering women's
health and politics and the intersection of the two. Her work has appeared in
the Village Voice, Ms., The Nation, Salon.com, Mother Jones, ELLE, and Plenty.
Her investigative pieces have tackled such provocative issues as police
harassment of street prostitutes, rape in the military, abortion tourism, and
the politics of sex ed. A former editor at Ms. magazine, Jennifer was also a
senior editor at the eco-lifestyle magazine Plenty and served as an editor of
the revised classic, Our Bodies, Ourselves. She lives in Brooklyn, New York.