Health & Social Policy

Safe, Affordable and Evidence-Based Maternity Care in the U.S.

As the palliative care and hospice movement figured out long ago, over-medicalizing and dehumanizing a natural human function doesn’t necessarily yield better outcomes or greater patient satisfaction – though it does guarantee that the cost will rise for taxpayers footing the bill.

That same lesson may apply to the way that we approach birth in America. Perversely, by increasing spending on high-tech maternity care, modern obstetrics has created a system that frequently ignores the most fundamental rule of medicine: First, do no harm.

The rate of cesarean sections skyrocketed from 20 percent of births to more than 32 percent in the last decade for no clear medical reason. Obviously, a small percentage of women need surgery to safely deliver their baby, but the World Health Organization estimates that the cesarean rate should not be higher than 10 to 15 percent. Women with one cesarean under their belt are typically pushed into repeat surgeries in subsequent pregnancies, though the American Congress of Obstetricians and Gynecologists recently admitted that many patients should be allowed a trial of vaginal birth after cesarean (VBAC) labor. Health risks to both mother and baby rise with each repeat section.

For the discriminating consumer, there are ways to avoid a surgical birth – for example, by remaining uninsured. Nearly 34 percent of privately insured patients underwent C-sections in 2006, compared to just 25 percent of uninsured women. Similarly, women birthing in private rather than not-for-profit hospitals have a 17 percent higher chance of undergoing a surgical birth, suggesting that the profit motive may trump health concerns.

Along the way, women in the hospital delivery room face a slew of costly and painful interventions that often don’t hold up as evidence-based medicine, such as episiotomies, artificially-induced labor, continuous fetal monitoring, the overuse of drugs such as Pitocin to speed up delivery, and a lack of mobility and food during labor. Meanwhile, obstetricians don’t typically take advantage of low-tech interventions that have little risk and excellent outcomes, such as the birth tub, or “aquadural.”

Current billing practices provide little incentive for physicians to curb unnecessary medical practices. An OB can schedule a C-section weeks in advance, perform the operation in about 30 minutes, bill $12,000 and be home in time for dinner. Meanwhile, even an uncomplicated hospital vaginal birth will likely stretch on inconveniently for hours, and cost only about $7,000.

This “the higher the cost, the worse the service,” isn’t a model that many businesses would find sustainable, but it’s the reality faced by millions of child-bearing American women.

There is an alternative. Licensed midwives provide safe, affordable and deeply humanistic care in a home or birth center setting. According to the most recent data from 2007, about 1 percent of American births take place outside of a hospital. But those numbers appear to be rising as women seek out a different kind of birth experience.

Obviously, a woman’s birth attendant and birth location represent deeply personal choices. But the public health and economic implications are vast.

In 2007, 25 percent of patients discharged from U.S. hospitals were childbearing women and their babies. Medicaid covers 40 percent of the nation’s four million-plus annual births, to the tune of $39 billion.

However, Medicaid does not recognize or reimburse licensed professional midwives, meaning women who want an out of hospital birth must pay the fee – approximately $2,500 – out of pocket. Many private insurers also refuse to cover homebirths, though they reimburse providers who perform elective c-sections. Certified professional midwives still are not legally authorized to practice in 23 states, though 18 of those have introduced or are planning to introduce legislation.

Government officials on both a federal and state level are looking for ways to contain soaring health care costs. The Texas House Committee on Appropriations and the House Committee on Public Health share an interim charge this session seeking “policy changes to promote best practices, reduce costs, and improve quality,” in Medicaid and other health programs. They could take a step in the right direction by supporting insurance reform to improve access to midwives.

An emerging body of research shows that for low-risk pregnancies attended by a professional midwife, with procedures in place in case a hospital transfer is indicated, homebirth is at least as safe as hospital deliveries, and carries a far lower risk of harmful and unnecessary interventions.

But midwifery advocates face a powerful adversary. The American Congress of Obstetricians and Gynecologists has launched an all-out war against homebirth, dismissing it as “the latest cause célèbre” and urging mothers not to risk the lives of their babies for the pleasures of a spa-like, candle-lit birth. Their lobby fights midwife-friendly legislation and spreads the politicized message that only hospital birth is acceptably safe.

For example, a meta-analysis published this month by Joseph Wax in the American Journal of Obstetrics and Gynecology reported that homebirths were associated with a tripling of the neonatal mortality rate.

By the most charitable standards, Wax’s meta-analysis was deeply flawed, pulling many of its mortality figures from a 1980s study of homebirths in the rural Australian outback and a similarly dated and poorly laid-out study of birth certificate data from Washington State two decades ago. Many of the studies failed to differentiate between planned midwife-assisted births and emergency unattended births, and also included high-risk patients in the data set. Birth activist Amy Romano dismissed the Wax study for relying on “a confidence interval you could drive a truck through.”

The Wax meta-analysis also neglected to include the best, most local and most current data we do have on homebirths – a study of 98 percent of all American homebirths attended by a certified midwife in 2000, which showed similar mortality rates as hospital births.

To improve birth safety, America should follow the two-pronged Canadian and European model – encourage access to trained, licensed and regulated midwives, while creating a non-adversarial system in which midwives work hand in hand with physicians. Meanwhile, hospitals must be pushed to bring their maternity standards in line with best practices.

Women deserve to have access to safe, affordable and evidence-based maternity care, whether they choose to birth in or out of the hospital.

Biundo delivered her son at home attended by a midwife.

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