Midwives Deliver

Jennifer Block

America is overspending and under-serving women and families. The problem is not access to care; it is the care itself.

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:

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

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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. 

This article was first published by the Los Angeles Times.

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