Midwives Deliver

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

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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  • invalid-0

    As pointed out at the end of this article, it was previously published in the LA Times. And as someone pointed out on the LA Times website blog, the c-section rate for lay midwives should be 0 % since lay midwives do not do surgery and deal with only low risk patients. The study from Washington State makes it sound like 12 % of women who tried to deliver at home should have been at the hospital in the first place. I suspect a 12 % c-section rate is very typical in any hospital in America if you include only uncomplicated pregnancies in women with spontaneous labor, especially if they have had a vaginal birth previously. The comparison is not really valid and really does not lead to any health care savings.

    It seems the major problem here is the legal system. Fear of lawsuits is the major factor in the high rate of c-sections and inductions of labor. Also lawyers will certainly sue any obstetrician involved in a bad outcome when the original plan involved a home delivery, see this story from Cleveland – http://blog.cleveland.com/metro/2008/01/the_only_significant_undispute.html. This lawsuit asks for $ 13 million dollars in damages because home birth is more dangerous than hospital birth and the doctor allegedly failed to tell the patient about this fact. One $ 13 million dollar lawsuit wipes out all the savings in Washington State for several years.

  • invalid-0

    Great post – so happy to see this here!

    I don’t know details about the Washington study, but it sounds like they controlled for high-risk births, so the comparison with birth center care would be valid – excluding those women who know they’ll need a c-section (like if they have placenta previa, etc). Also, contrary to Anonymous’ assertion, studies have found that home birth is not, in fact, more dangerous than hospital birth for low-risk pregnancies.

    Insurance companies are strangely clueless about cost savings generated by midwifery care. In the Washington DC area, we’ve had a birth center close in part because of low reimbursement rates, and another is in danger of losing coverage from Blue Cross. I’ve heard literally dozens of women talk about struggles to get their out-of-hospital births covered. Midwife care is something women in Europe and elsewhere can take for granted – yet here we have to fight tooth and nail just to be able to consider it.

  • invalid-0

    did the DC birthing center have to close due to rising malpractice insurance?

  • invalid-0

    I wish I had had a midwife.

    I had two hospital deliveries without any pain meds or even a doctor. But I did get a huge hospital bill to me and my insurance for the virtual non-care I received.

    Hospitals are locked into a birth paradigm that is not normal.

    It is like they are against what is normal.

    Women need support and comfort and to be updated. Instead we get unneccessary interventions foisted on us for the protection of the hospital and practitioner.

    The concept of being in a hospital in case you may need help has been corrupted to the point that women and even nurses are just expected to follow arbitrary rules for the protection of the hospital.

    I don’t even think the staff like the rules.

  • invalid-0

    The birthing center in DC is still open – the birth center in Bethesda, Maryland closed in 2007 for a number of reasons, but the major ones as I understood them were the high cost of malpractice insurance and the low rates of reimbursement from health insurance companies – in other words, many companies give birth centers a lower facility reimbursement than the birth centers’ actual cost for a woman’s stay in the center, leaving them to make up the difference.

  • jennifer-block

    Midwives who attend out of hospital births have about a 4% cesarean rate. That doesn’t mean they do the surgery! That means that 4% of the women they attend transport to the hospital and undergo a surgical delivery, carried out by an obstetrician in an operating room. About 12% of women who plan home births in North America end up transporting, but most still have a vaginal birth.


    The fact is that low-risk women who plan hospital births with traditional care have a 19% cesarean rate (and that’s according to data that’s a few years old–it’s probably higher now). That’s nearly 5 times the midwives’ rate out-of-hospital. That means cost savings–and lives saved.


    The point is that fewer women seem to need high-tech, expensive, risky medical intervention when the normal, physiological birth process is supported. Many studies show that midwives do a better job of supporting that process–that’s what they’re trained to do.


    Hospitals make sense–indeed, we need hospitals–for risks, complications, and emergencies, but there is nothing in the literature showing that healthy women–or their babies–are safer birthing in the hospital. The studies show that those babies do just as well born with a trained midwife in attendance (therefore, not "lay"), and that their mothers do better.


  • invalid-0

    please give your source for this stats.

  • invalid-0

    please give your source for these stats.

  • invalid-0

    I did a search on the CDC’s website for c-section stats and there was a analysis of the reason for first time c-section in women in Washington state – 25 % were for breech (foot first) 9 % were for diabetes, 5 % were for high blood pressure, 5 % were for bleeding, 5 % were for premature labor, 10 % were for abnormal heart beat in the fetus, and 4 % were for twins.

  • jennifer-block

    The two largest studies of out-of-hospital birth in North America are: Daviss and Johnson, British Medical Journal, 2005; Rooks et al, New England Journal of Medicine, 1989. The 19% stat comes from the CDC/National Health Statistics. Also see the recent Cochrane review of midwife-led care: http://www.cochrane.org/reviews/en/ab004667.html.

  • invalid-0

    The British Medical Journal article has been widely criticized because of a lack of comparison group. If you compare low risk women planning a home birth vs. everyone else including twins, women with medical problems etc. Of course there is going to be a higher c-section rate and other problems.

    Other well done studies with a comparison group have shown potential safety problems with home birth. A Swedish study in 2008 found the newborns were three times more likely to die during a home delivery compared to an in hospital birth. A similar American study published in 2003 looked at 7 years of data in Washington state, and these authors concluded home birth doubled the risk of newborn deaths. An editorial in a British journal in 2008 pointed out the Dutch have a 30 % home birth rate and have the second highest newborn death rate in Europe.

    It seems the homebirth argument is based on comparing apples to oranges. Since many c-sections are done for breech presentation, twins and maternal diseases (as posted elsewhere here), it is not legit to compare uncomplicated pregnancies to these situations. Uncomplicated deliveries can be accomplished at home but there will be a price to pay when an emergency arises. The American, Swedish and Dutch stats are quite similar in this regard.

    • invalid-0

      @ Concerned MD:

      The BMJ published study from 2005 “Outcomes of planned home births with certified professional midwives: large prospective study in North America” compares low risk planned home birth with low risk hospital births, apples to apples.

      You can read it here:

      The whole study is worth a read, but here is the conclusion, which among other things addresses your unfair comparison concerns (emphasis mine):

      Conclusion: “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”

      Also, I’d love to see more specific references to the studies you are citing. It’s the internet age after all. Links would be appreciated, even if it’s only to article abstracts.

      • invalid-0

        I am sure these references will be easy enough to find with a good search engine – the text in the links is huge and hard to post here.

        The British article was in the medical journal the British Journal of Obstetrics and Gynecology or BJOG as an editorial in April 2008.

        The Swedish study was in a medical journal called Acta Obstetricia et Gynecologica Scandinavica.

        The American study from Washington state was in a journal called Obstetrics and Gynecology and it was actually in August 2002.

        The Washington state study is the best of the bunch because it is based on birth certificate data and therefore unbiased by the authors’ opinions. The trouble with the BMJ is two fold – one is the conclusion could easily be “we asked our friends to tell us about their good outcomes, and our good outcomes are better than yours.” The other problem is the authors for BMJ studies are home birth advocates and really did not disclose that fact at the time of time of publication. Big public health decisions need to be based on the best available data.

  • http://www.insuresaver.com invalid-0

    Midwives are the most underrated medical professionals ever. They are often overlooked by people because they’d rather consult a doctor who knows better than them. It’s a common misconception actually. Let’s just hope Obama stays true to his health reforms. Healthy population = strong workforce

  • invalid-0

    If the Washington State study being referred to is the one by Pang, et al. (which I’m guessing it is, as it was published in Obstetrics and Gynecology in 2002) then the Anonymous poster needs to review it again. In his book “Born in the USA” Marden Wagner, M.D. M.S. (a perinatologist and scientist) does a wonderful job of explaining why the Pang study is NOT “the best available data”. In fact in spite of Anonymous’s assertion that birth certificate data is unbiased and therefor better does not account for the fact that, as noted by Pang et al. in their study: “A study by Meyers et al. showed that birth certificate data correctly identified attendant type for out-of-hospital births 30 percent of the time”. How is 30% accuracy “the best available data”???
    Pang et al. admit in their study that “Since we tried to minimize misclassification, but had no possibility to eliminate it, there remains potential for a significant amount of misclassification of accidental or unplanned home births as planned home births”, and that “the misclassification of any unplanned home births as planned home births in this study would result in inflated risk estimates of neonatal mortality”. Furthermore, Pang et al. concluded that “Future observational studies using a study design that accurately assesses the intention to deliver at home are needed”, which is exactly what the North American study published in the BJM in 2002 did, finding pregnant women who were *planning* home births and following them to get accurate data about their outcomes.

  • http://midwifes-journal.blogspot.com invalid-0

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