Great Midwifery Article in the LA Times

Here’s a wonderful pro-midwifery article in the LA Times!

I also have the text here:

Midwives deliver

America needs better birth care, and midwives can deliver it.

By Jennifer Block
December 24, 2008
» Discuss Article (23 Comments)

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: 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% 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 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% 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.

Jennifer Block is the author of “Pushed: The Painful Truth About Childbirth and Modern Maternity Care.”

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Choosing a Birth Attendant

Most people see pregnancy as a time to prepare for the baby.  I see early pregnancy as a time to figure out what you want before you even go to your first appointment.  A lot of women don’t even think about the actual birth until a few months or weeks before the baby is born!  It can be difficult to make a change that late in the game.  You should choose the provider who has the same philosophy as you instead of hoping to change them by the end of the pregnancy.

Tips for choosing a birth attendant

  • Think about your core birthing philosophy.  Do you feel that birth is a natural physiological process?  If so, a midwife is your best bet.  Do you have physical issues that dictate that there could be a potential problem?  Do you see birth as dangerous with lots of opportunities for things to go wrong?  Then an OB might be your preferred provider.
  • Visit The Birth Survey, a consumer reporting site dedicated to birth.  Go to rate your OB, midwife, and place of birth.  As of now the site is just up and running and they should have formulated the results by Fall of 08
  • Get recomendations from people who share your birthing point of view, visit online forums (like mothering.com) and ask questions.
  • Interview your potential care provider.  Remember, they are working for you, not the other way around.  Related posts:  Interviewing your OB, Interviewing your Midwife, and Interviewing your Place of Birth
  • Create a birth plan well before your second or third trimester.  Going to your provider interview with a birth plan or at least an idea of what you want can help you ask the right questions.  Just make sure to not be negative or badger the doctor!
  • How much one-on-one, hands-on support do you want during pregnancy? Midwives generally treat the whole woman:  mentally, physically, socially, psychologically, spiritually.  Prenatal appointments generally last about an hour and they are usually there for the majority of labor and birth.  OBs on the other hand are primarily surgical specialists who have a prenatal appointment time of about five minutes and generally just come in at the end to catch the baby.
  • How much involvement do you want in your pregnancy and birth? Many times in midwifery practices the mom gets to do her own urine dip and weigh herself at her appointments.  The midwife tries to explain things to her and tries to get her to interact during her visits.  An OB visit is more in-and-out with the nurses doing everything behind the scenes.
  • Where do you want to give birth? Some women just go to an OB because they think they’re supposed to and then realize late in pregnancy that they want a home birth!  Where you give birth automatically dictates who will be there.  For example in Colorado at this time, OBs work in the hospital, only Certified Nurse Midwives (CNM) can work at a birth center, and Certified Professional Midwives (CPM) and CNMs can do home births.  Most CNMs (90-95%) work with doctors in the hospital.
  • Do you want to have a waterbirth? Some hospitals allow it, some do not.  If you have to give birth in a hospital and want to fight a policy that does not allow waterbirth, having a provider who supports it can go a long way.  Yes, it is possible to change hospital policy!  In Gentle Birth Choices Barbara Harper talks about how to do this.
  • Choose someone you’re comfortable with. If you’re not comfortable with your provider there is no way you can let your body open up and relax enough to have a baby.
  • If a provider or place (like home or birthing center) is out of your insurance network, talk to your insurance provider.  Also, often times a home birth or birthing center is cheaper even though you have to pay in full.  For example, in Colorado a typical, no-intervention birth in a hospital usually costs around $12,000-13,000.  In an insurance plan where you pay 10% of hospital and doctor’s costs you’re looking at a few thousand dollars.  A home birth or birth center birth usually costs around that if you’re paying in full.
  • Do you feel more comfortable with a male or female doctor?  Remember that just because a doctor is female doesn’t mean she believes in the same birthing philosophy as you do.