Midwives can deliver better birth care, if we let them

Service is cheapest, most health-promoting maternity care for healthy women
By JENNIFER BLOCK

Some health care 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 percent 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: Black 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 percent of midwifery patients in Washington ended up with C-sections, compared with 24 percent of low-risk women in traditional obstetric care.
Currently, just 1 percent of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10 percent or even 30 percent. 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 percent.
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 health care 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.

Block is the author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care." This article originally appeared in the Los Angeles Times.