All of us who are here were born. We should care deeply about the maternity care system we have, as it has affected every one of us. The U.S. just fell for the third straight year in the WHO international statistics for maternal mortality (from 41st to 50th to 58th, but who’s counting?) and holds the unenviable distinction of having the worst such outcomes in the developed world. In addition to low outcomes, we’re also the most expensive. Despite the fact that about a quarter of hospital discharges are moms and babies, some $98 billion a year worth, and 43% of those births are paid by Medicaid (your tax dollars), few policy makers seem to be paying much attention to maternity care. This was on my mind last week as I attended the National Academy of State Health Policy (NASHP) in my home town of Seattle.
The best research tells us that the usual suspects for our poor maternity outcomes are not the culprits. We would love to blame the victims(they are too fat, too unhealthy, the wrong race, etc.) or the liability system, but none of these factors explain our trends in out-of-control cesarean rates, prematurity, low birth weight, neonatal mortality (ranked 37th) and similar key indicators of the health of the maternity system. Folks, it’s The Management. Check it out at www.birthbythenumbers.org for instance, or do your own research. The bottom line: It’s how we take care of women and what we tell them that they and their babies “need” that ultimately effects maternal health choices. The things that are communicated to mothers truly makes the difference in maternal care, like insisting on things like electronic fetal monitoring, which was de-bunked for low-risk women way back in the 1990s, and that women can’t deliver “big” babies normally without serious injury to mom and/or baby. Hey, when you’ve witnessed a 100 pound woman deliver her first-born, a 10 lbs. 1oz baby, without a scratch (or an epidural), you come to believe in the power of women.
A major study was published this year that shows that a solution to our poor maternity outcomes is the kind of care women get with midwife-led care in free-standing birth centers. For instance, it shows that for low-risk women who would have been eligible to have their babies in a birth center, but who chose the hospital, the cesarean rate was 24%, much better than the national average of 33%; for similar women who birthed in a birth center, it was 6%. The study’s other main point is that these good outcomes in birth centers are virtually identical to those of the prior such study in 1989, i.e. while the rest of the U.S. maternity system has been going off the rails, the birth centers have continued to “do their thing” in a safe, satisfying way.We’re talking major abdominal surgery which significantly increases risks to both mom and baby .
Why would we do all these surgeries if they aren’t really necessary? It’s hard not to wonder if it all goes back to finances. For example, during my practice a hospital administrator once said to my face that if he couldn’t get babies into the NICU, he’d have to close Labor and Delivery. Filling the operating room ( which is where cesarean births occur) also helps hospitals gain more money.
Another question to consider is why we don’t provide access to midwives and birth centers for every woman. The list of reasons is very long, but since health care is a business in this country, a lot of it comes down to money. Physicians’ residencies, and the hospitals that train them, are paid for by Medicare; midwives and the birth centers that train them are not covered by Medicare. Although the Affordable Care Act mandates that birth centers are a covered entity, just as hospitals, ambulatory surgery centers or nursing homes, three years after the enactment of the legislation, nearly half the states are not yet complying with the law, and among those that are, many are not paying birth centers enough to operate.
So I can “disrupt” all day long—and I do!—but what it’s really going to take to change our maternity system is for women to start doing their own research about their options and demand better care. Join with others who want women to have access to evidence-based care through organizations like www.improvingbirth.org . Women demanded better in the ‘70s and got it, however we have lost our way. It is time we demand it again.
Cynthia Flynn received her BA from the University of Washington, her MA and PhD from the University of North Carolina, Chapel Hill, and her MSN from Yale University. She has served as Executive Director of The Birth Center, Bryn Mawr, PA; the General Director of Family Health and Birth Center, Washington DC; Associate Professor of Nursing at Seattle University; founder/owner of Columbia Women’s Clinic and Birth Center, Kennewick, WA; and Past President of the American Association of Birth Centers. She serves as the Expert Midwife on www.pregnancy.org, and provides consulting for organizations wishing to start, expand or replicate birth centers in order to increase access for healthy women to a proven method of obtaining a healthy delivery.