The Disturbing State of Maternity Care in the US
Peace on Earth Begins with Gentle Birth(click for the interview)
FOR several years running, maternity outcomes in the United States for both mothers and newborns have fallen in rank compared to other countries. According to the latest World Health Organization (WHO) statistics, 33 countries do a better job of keeping newborns alive and 59 countries do a better job of keeping expectant mothers alive than the U.S. The U.S. is the only developed country whose maternal mortality rate has risen since 1990.
The statistics for morbidity (the incidence of disease or complications) are similar to those for mortality. In addition, the WHO reports that the overall cesarean rate should be between 5 percent and 15 percent in order to prevent unnecessary morbidity and mortality. The U.S. rate has climbed from 20.7 percent in 1996 to 32.7 percent in 2013, and has been more than 30 percent since 2005. Yet the general public remains blissfully unaware of the risks of pregnancy in the US, and most people actually believe we have the best maternity care in the world.
It’s not like finding a cure for cancer; we already know how to improve US maternity care. Each day, some 10,700 women give birth in the U.S., of which 70% (some 7,500) would qualify for birth center care with midwives. However, fewer than 32 of these 10,000+ women actually receive birth center care. Only about 8% (850 of the 10,700) of US babies are born each day into the hands of midwives, as compared to Finland, where the figure is 78% of the babies, and Finland’s outcome statistics are 3–4 times better than ours.
Instead, the majority of US women are receiving care in hospitals with doctors, care that is more appropriate for the minority of women with truly high-risk conditions, care which results in poorer outcomes for lower-risk women than they could have had in birth centers (or at home). A well-designed 2013 study showed that women who are low enough risk to qualify for birth center admission at the onset of labor have a cesarean surgery rate of 26% IF they choose to be admitted to a hospital, but just 6% if they choose a free-standing birth center (FSBC). The risks for mother and baby from this excess 20% rate of cesareans, plus the economic cost to both families and society, are enormous and unnecessary. Low-risk women are routinely told that the cesarean was an “emergency,” when in fact it was too often the result of sub-optimal care. In addition, women who birth in FSBCs report higher satisfaction with their births. Thus, birth centers satisfy the Triple Aim of better outcomes at lower cost with higher client satisfaction.
Perhaps two of the best-known examples of birth centers that serve primarily women of color are The Birth Place in Winter Garden, FL and Family Health and Birth Center in the District of Columbia. In both cases, the rates of prematurity, low birth weight and cesareans are a fraction of the national rates, and the breastfeeding rates at discharge — even for African Americans — are 100%. Evidence from the 50+ birth centers participating in the Strong Start for Women and Newborns Initiative show similar outcomes for Medicaid-insured women, with outcomes far better than the national averages, even though the Medicaid population has more social, economic and health considerations than the general population.
So Why Aren’t Midwives and Birth Centers the Standard of Care for Healthy Women, especially minority women who have the poorest outcomes? There are several reasons why birth center growth has been slow. While many of the reasons relate to public policy, particularly for mothers covered by Medicaid and Medicaid Managed Care, other barriers to expansion are lack of adequate reimbursement from both public and private insurers, restrictions on the practice of midwifery that are not backed by scientific evidence, and lack of interest from investors with capital. Also, even though there are more hospital discharges each year related to birth than any other diagnosis (with the resulting associated expense), there has been an amazing lack of attention to this event that we all experienced, one way or another. There has been much more attention paid to asthma, diabetes, and heart disease, all of which are affected by what happens in the perinatal year.
The Time for Midwives and Birth Centers is Now
While the continuing discussions of health care reform have put the issues of reducing health care costs and improving the quality of care higher up in the nation’s awareness, it is on the state level where the cost and quality issues of maternity care become pressing, because more than 40% of all births are covered by Medicaid. Some states are realizing that midwifery and birth centers are not just providing maternity care at less expense for the perinatal period, but they are also reducing downstream lifetime health care costs for both mothers and children, because of the better outcomes of midwifery care during the perinatal period.
As hospitals close their labor and delivery units (19 closures of 26 units in the Philadelphia area, for instance), there is increased demand for and necessity for an alternative. Further, more than half of the 3000+ counties in the U.S. lack a physician who provides maternity services, and the number of physicians who provide those services is decreasing, thus providing an opening for midwives. The American Congress of Obstetricians and Gynecologists now recognizes that using midwives in a freestanding birth center is a safe and appropriate option for maternity care for lower risk women. One by one, past barriers are coming down.
A better approach
It is time to dramatically improve maternity outcomes, especially for women of color. It is time to correct the cultural mistake of characterizing childbirth as a medical event that requires hospitalization of the mother and newborn. We should be changing maternity care in America from the medical model to a wellness model. In a shared decision-making approach, the midwives are the primary providers who provide pregnancy care, labor support, birth in a freestanding birth center, breastfeeding support, post partum care, and assessment and referral of any woman or baby that does not meet the low risk criteria of the birth center model in consultation with the pregnant woman. And every woman should have the choice of a freestanding birth center that provides this support in her own neighborhood.
We need to agree that:
- For the majority of women, childbirth is a normal biological event, not a medical emergency. Women who have the proper support and education can birth their own babies without medical intervention
- Birth can be a transforming and empowering experience
- Each woman deserves care that is culturally sensitive, holistic and family centered, based on the best available science
- Each woman deserves to be in control of her health (in mind and body) and to feel empowered by her healthcare provider to make educated decisions about her own care. The woman’s needs always come first
- We need to reduce out-of-pocket costs for families, and eliminate unnecessary costs for payers, including government entities
- Healthcare decisions are best made with input, trust, mutual respect and continued partnership between the woman and her provider. Women deserve more than a 5-minute “belly-check.”
- The midwifery model of healthcare is helpful for women in all stages of their lives and without regard to their risk status.
- Hospitals are for sick people, not healthy people experiencing a normal life event
To achieve these goals, we must challenge the maternity care system at its core, and create a deeper partnership between providers and the women they serve. We can start by using midwives for our own care, including our well-woman care. We can support the birth centers near us and help start them in areas where there is no access. We can support midwifery educational programs. We can teach our daughters — and their future partners — that they are strong and capable of growing, birthing, breastfeeding, and parenting healthy children. If women can run for President, complete a marathon, fly to the International Space Station, or win a Nobel Prize, surely they can have a baby. Most importantly, we can tell the truth about the state of US maternity care, and how to improve it.
© Cynthia Flynn, CNM, PhD, FACNM
Note from the Sistas: We are going to continue this series as the statistics involving problem births for women of color is mind boggling. Dr. Flynn told us; if you eat more protein during pregnancy your water won’t break prematurely. Dr. Flynn as also agreed to take questions on our FB page “The Conversation”; see you there.