Protecting Reproductive Rights at Delivery

Jill Alliman

Despite the financial resources commanded by hospital-based birth services, many experts, economists, and advocates are alarmed at the state of U.S. maternity care, which is driven by high rates of unproven medical interventions.

When one thinks of the term “reproductive rights,” one’s first thought usually goes straight to issues of abortion or contraception.  An often-overlooked reproductive right, however, is a woman’s right to a non-interventional vaginal birth in her chosen setting, and with the provider, of her choice.  Yet, at least 84 percent of women will experience childbirth at some point in their lives.  At the present time, this important reproductive right is endangered.

An estimated 4.3 million births take place in the U.S. every year.  Fewer than 10 percent of these births are attended by midwives and only about one percent take place outside of hospitals. Childbirth is the most common reason for hospital admission in this country.  The cost of this care is a staggering $86 billion dollars per year,

Yet, despite the financial resources commanded by hospital-based birth services, many health care providers, public health experts, economists, and activists are alarmed at the state of U.S. maternity care, which is driven by high rates of unproven medical interventions.  These interventions – such as mandatory electronic fetal monitoring, labor induction and epidural anesthesia — have over-medicalized childbirth and contribute to a national c-section rate of almost 32 percent — a shocking 51 percent increase in the last 10 years.  Twenty percent of those c-sections are primary, meaning the woman has not had a previous c-section. 

The c-section rate in the U.S. is among the highest in the world, second only to Brazil. Women and their health care professionals have good reason to be concerned about high rates of cesarean section, because c- section is associated with a two-to five-fold increase in the risk of maternal death during childbirth.  Studies by the Centers for Disease Control (CDC) and March of Dimes strongly indicate that babies born by c-section are also at a higher risk of death or morbidity, including asthma and other respiratory problems.  Babies born by c-section also account for higher rates of admission to hospital neonatal intensive care units (NICUs).

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It should be no surprise, therefore, that an increasing number of pregnant women wish to opt out of the risks they consider inherent in hospital birth. Many of these women seek a safe place where pregnancy is not viewed as an illness and they can experience natural childbirth.  An important option for natural childbirth is the freestanding birth center*– an out-of-hospital facility where unmedicated vaginal birth without unnecessary interventions is supported and encouraged.   Studies show that women who are admitted to a freestanding birth center in labor have a c-section risk of less than 10% compared to the overall cesarean rate of 31.8 percent.  Birth centers can play an important role in avoiding the first c-section, which often leads to c-sections in later births because of the present unwillingness of many obstetricians and hospitals to support vaginal birth after cesarean delivery, also known as VBAC (pronounced “vee-back”).

The American Association of Birth Centers (AABC) believes that access to high quality maternity care and the choice to have a natural vaginal birth are basic reproductive rights for all women.  These rights are protected in freestanding birth centers using the midwifery model of care.  This is an issue that all reproductive rights activists can  support, regardless of one’s beliefs about abortion.  Those women who choose to carry their pregnancies to term have the right to high quality care with the provider of their choice and in the setting of their choice during pregnancy and childbirth.  A recently-published Milbank report, Evidence-based Maternity Care: What It Is and What It Can Achieve, has publicized the fact that unnecessary medical interventions in pregnancy and birth are not only costly, they do nothing to improve the health of mothers or babies.

Recent federal action, however, during the Bush administration, has threatened access to birth centers for women on Medicaid.  The Centers for Medicaid and Medicare Services (“CMS”) denied federal payment to states to cover the federal share (about one-half) of state Medicaid payments to birth centers.  These CMS denials began in Washington, Alaska, South Carolina, and Texas, at which point the AABC took action by working to encourage passage of legislation that would specifically add birth center services to the list of all services covered by Medicaid.  

The Birth Center Medicaid Reimbursement Act has been introduced and has won bi-partisan support from many members of Congress, including strong sponsors from the Senate and House committees that are handling health care reform. However, given the many swirling issues of political debate over health care reform at the present time, this bill needs even wider support to insure passage this year.

Nearly half of all births in the United States are paid for by Medicaid. Access to maternity care is vital for women in underserved communities, and access to birth center care has been shown to lead to better outcomes for women who are vulnerable to poor outcomes as a result of various socio-economic factors. The birth center is the facility where all women can access care by midwives, and where the right to a natural vaginal birth can be preserved and protected.  If birth centers do not have equal footing with hospitals under the federal Medicaid program, low income women will not have access to this option and states will not realize the cost-savings associated with birth center care.  Economist David Anderson, PhD, has calculated that an increase of just 5 percent in birth center deliveries could result in cost savings of $675 million per year.

In one rural Tennessee community, the twenty-five year old Women’s Wellness and Maternity Center insures access to care for women, 80 percent of whom are on Medicaid.  Another birth center, this one in Houston, Texas, estimates that 95 percent of its clients are Medicaid recipients. Without this access point, women would be entering prenatal care later and missing out on access to the kind of specialized care birth centers can provide, including group prenatal care with midwives, increased education about pregnancy and birth, and access to a counselor and outreach worker – all of which are available in the birth center.  Typical birth center outcomes such as c-section rates as low as five percent and an 85 percent breastfeeding rate add to the benefits of the community birth center.

Without passage of the birth center bill, however, the right of low income women to access this excellent care is threatened and the continued survival of birth centers in some communities is likewise at risk, which could result in lack of access by all women, including those with health insurance. We need the help and support of across the spectrum on this issue which is truly one on which all can find common ground.

To find out more about the Medicaid Birth Center Bill and how a woman’s right to choose a normal vaginal birth can be protected in birth centers, go to:  

*What Is a Birth Center?  Freestanding birth centers are health care facilities, usually licensed by the state in which they are located, which provide a warm, caring, and home-like setting for childbirth.  AABC likes to say that birth centers are “maxi-homes,” rather than “mini-hospitals.”  Birth centers are typically operated and staffed by midwives (and some physicians) whose focus is woman-centered throughout the pregnancy and birth, offering prenatal care, childbirth education, labor and delivery services, post-partum and infant care and, often, well-woman primary care and family planning services.  

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