April 15, 2011
“In today’s system, 98 percent of mothers give birth in a hospital—the majority of them under the care of an obstetrician. One in every three births will occur surgically via cesarean section. Most women are lying in bed during their labor, without food or water, restricted by monitors strapped around their belly that measure fetal heart rates. The majority of women opt for an epidural, the spinal medication that numbs the body from the waist down. Inductions (provoking or encouraging labor progression with drugs like pitocin) are common practice.
We’ve arrived at this standard for childbirth care through a purposeful and calculated campaign on behalf of the medical establishment. Up until the early 20th century, childbirth always took place in the home, attended by midwives. In a span of about 30 years, doctors were able to convince women (and their husbands) that the hospital was the best place to give birth. The profession of midwifery was almost entirely eliminated in the U.S. through this campaign. Not only did doctors convince women to give birth with them in hospital, they also convinced the general public that birth at home was dangerous and risky—an idea that still prevails today, vigorously promoted by both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA).
The idea of homebirth as risky and midwives as inadequate providers contrasted with the realities of the move from home to hospital for birth—maternal mortality rates actually increased in the first few decades that women began birthing in hospital.
Ina May Gaskin, a well-known midwife, explains in her new book “Birth Matters: A Midwife’s Manifesta” that this was due in part to lack of knowledge of disease transmission as well as lack of development in surgical techniques. She also explains that much of medical knowledge about childbirth and the female body was developed from autopsies on women who had died, rather than the observation of live women giving birth. The result was a rise in maternal and infant mortality in Washington, D.C., New York, New Jersey and Boston, all cities where more hospitals were established and, thus, where more births took place.
Meanwhile, hospital birth took a different path for women of color and low-income women than it did for white women with access to resources.
Before Medicaid was established in the 1960s, women of color and low-income women had little access to hospital birth because they couldn’t afford to pay for it. In the rural South, midwifery thrived until the ’70s and ’80s. Women of color in urban cities in the North moved into the hospitals more quickly, in part because laws outlawing midwives were enacted more quickly there and in part because the teaching hospitals in these areas wanted more birthing women to learn on. One doctor even paid immigrant women to birth at his Chicago hospital, according to Gaskin. Once Medicaid was enacted and provided reimbursement for obstetricians and hospital birth, it signaled the end of the midwifery era, as doctors made the final push to bring all of birth into their domain in the hospital now that they were guaranteed payment for the services.
Financial gain has long been a motivating factor at the root of the modern maternity care system— and it helps maintain the status quo today. Childbirth remains the number one cause of hospitalization for women in the U.S. A hospital birth will cost anywhere from $8,500 for an uncomplicated vaginal delivery to upwards of $20,000 for a c-section with complications. Taxpayers shoulder a significant portion of this burden, through the rising costs of programs like Medicaid, which cover the costs of millions of births each year. Meanwhile, many of those who have chosen (in increasing numbers) to give birth with a midwife at home often end up paying out of pocket for those services because many private insurance companies do not cover them.
Despite all the efforts of the medical establishment, the midwifery movement has revived itself in recent decades. Certified Nurse Midwives (CNMs), who usually practice in hospitals, are on the rise. Certified Professional Midwives (CPMs) who are trained to provide out-of-hospital care are also a growing group. The health care reform battle last year presented new opportunities for midwifery advocates to expand access through federal legislation. Midwives and consumer advocates rightly pointed to potential cost savings for Medicaid specifically and health care overall. The advocates were successful in one aspect: they were able to get birth centers run by licensed midwives covered by Medicaid as an amendment to the Affordable Care Act.
Legislation introduced last month by Rep. Chellie Pingree, a Democrat from Maine, would take this a step farther by mandating that states that license CPMs also offer Medicaid coverage for them. Twenty-seven states currently license CPMs, and five of those started doing so in just the last six years. Advocates point to lower intervention rates and better outcomes for moms and babies with midwifery care, particularly out-of-hospital. This might be especially true for women of color. Gaskin explains:
Obstetricians don’t have the time or the training to provide the kind of care that actually prevents prematurity and low-birthweight. If CPMs could be reimbursed by Medicaid, more women of color could get into prenatal care early during pregnancy. CPMs aren’t under institutional constraints to do 10- or 15-minute prenatal visits. It takes time to provide the kind of counseling about nutrition and exercise that can prevent complications.
Gaskin also points out that CPMs regularly practice postpartum home visiting. This can be a life-saving practice for mothers who might experience complications after the delivery that could be missed during the standard six-week period before a postpartum visit for most OBs. The Safe Motherhood Quilt Project, started by Gaskin, documents the stories of thousands of women who have died due to childbirth complications, including a number of whom could have been saved by a postpartum home visit. Another piece of legislation introduced into the House last month by Rep. John Conyers from Michigan would also work to address maternal mortality disparities by mandating a system of reporting and investigating the maternal deaths at a national level.
Medicaid is a logical angle for the first federal effort regarding CPMs precisely because of the argument for cost saving. In Washington State, one of the first states to reimburse CPMs under the state Medicaid plan, officials reported $3.1 million in savings to Medicaid every two years from CPMs providing care to women on Medicaid. Almost 3 percent of births occur out of hospital there, more than twice the national average. And unlike in other states, the percentage of women on Medicaid using CPMs is equivalent to the percentage of women with private insurance using them.
For most women on Medicaid, unless they can afford to pay out of pocket for a home birth midwife (anywhere from $1,500-$5,000), hospital births are their only option. “Many [midwives] are forced to turn away women who are on Medicaid and want to give birth at home or in a birth centers,” explains Katie Prown, Campaign Manager with the Big Push for Midwives. “Because that service isn’t covered, they go to a hospital where automatically the cost will be two or three times what it could have been with a home birth.”