Obama "won't rest" until he's cut health care costs and improved quality?
Over here, Mr. President, says Jennie Joseph, a certified professional midwife who runs a birth center in Winter Garden, Florida. Midwives like Joseph provide what you could call "less-is-more care."
Compared to healthy women who get standard obstetric care and deliver on high-tech labor and delivery wards, women with low-risk pregnancies who get care with a midwife and deliver in birth centers or even in their own homes, benefit from a five-fold decrease in the chance of a cesarean delivery, more success with breastfeeding, and less likelihood that their baby will be born too early or end up in intensive care. And all of this for a fraction of the cost of the status quo.
A new economic analysis forecasts savings of $9.1 billion per year if 10 percent of women planned to deliver out of hospital with midwives. (Right now, just one percent do). If America is serious about reform, midwifery advocates are saying, "Hey, how about us?"
Childbirth, in fact, costs the United States more in hospital charges than any other health condition -- $86 billion in 2006, almost half paid for by taxpayers. This high price tag -- twice as high as what most European countries spend -- buys us one of the most medicalized maternity care systems in the industrialized world. Yet we have among the worst outcomes: high rates of preterm birth, infant mortality, and maternal mortality, with huge disparities by race.
In Orange County, Florida, where Jennie Joseph practices, one in five African-American babies were born premature in 2007. In response to these disparities, Joseph also runs a prenatal clinic that turns away no one and coordinates care with the local hospital. Among the women who got prenatal care "The JJ Way" in 2007, less than 1 in 20 gave birth preterm, and there were zero disparities. "It's not rocket science," Joseph told me. "It's really just about practitioners being willing to have conversations with women." Joseph is perhaps being coy, but whatever she's doing, we should be studying it very closely.
Midwives like Joseph aren't nurses or doctors. They don't offer epidurals, schedule labor inductions, or perform surgery. What they do is provide primary care for normal pregnancy and physiological childbirth, and they only intervene or transfer to the next level of care when needed. The model works. In a study of 5,000 healthy women who planned home births with certified professional midwives in North America, 96 percent gave birth vaginally with hardly any intervention, and their babies were born just as safely as similarly low-risk women who plan hospital births. The results track with other studies of planned, midwife-attended, out-of-hospital birth.
Standard obstetric care, on the other hand, routinely induces and speeds up labor, immobilizes women and has them push in disadvantageous positions, cuts episiotomies, employs vacuum extractors, and in nearly 1 out of 3 births, delivers surgically via cesarean section. This routine use of intervention is not based on medical necessity, and there's actually a vast body of evidence now showing that much of what we do in American labor and delivery wards is unnecessary, ineffective, and potentially harmful. Midwives like Joseph, it turns out, are providing evidence-based care...at bargain prices.
"The obstetric model of care right now does not empower anybody," says Joseph. "We're not getting high quality of care that enables us to have healthy outcomes. We've got the worst outcomes. Where do we think they come from? They come from a system that doesn't work."
Back in April I attended a symposium in Washington, DC, sponsored by the think
tank Childbirth Connection, called
"Transforming Maternity Care: A High Value Proposition." An impressive array of
stakeholders participated: seasoned physicians, midwives, nurses, hospital
administrators, health system executives, insurance officers, public health
officials, and NIH researchers met in workgroups for more than a year to evaluate
the current system and hammer out recommendations. There was remarkable
consensus that the system isn't working, that there are "perverse incentives"
for the overuse of medical intervention at the expense of maternal and infant
health.
A physician and chair of the United States Preventive Services Task Force reported:
"There's a shortage of providers whose training focuses on wellness," and even suggested that "we should support the education of providers, facilities, and insurance on the evidence that supports the safety of home deliveries for the appropriate low-risk women within the context of an integrated system of care."
A VP from WellPoint, one of the largest health insurers, said flatly: "You get what you pay for. What we are paying for now is high intervention, high cost, high procedural care." An executive from Geisinger Health System made a startling admission:
"There are many healthcare organizations across the country [that] have become, unfortunately, dependent upon NICU [Neonatal Intensive Care Unit] volumes to fund many of their other services."
In other words, our for-profit system not only rewards the overuse of intervention even if it leads to more sick babies; in some cases, it depends on it.
So, if this system is broken, and this system is wasting public funds, and this system is harming women and babies, why isn't fixing it part of the national conversation on health reform?
"We're sitting here in the birth community scratching our heads," says Susan Jenkins, an attorney who's on the steering committee of the Big Push for Midwives, a national campaign to license certified professional midwives in every state, and an advisor to the American Association of Birth Centers, both of which are lobbying congress for inclusion in health reform bills.
"Here we've got this huge sector of the healthcare dollar where we can save costs and improve quality. And it goes beyond midwives. It's about improving these really horrible outcomes. Why isn't anybody talking about this?"
It's a valid question, and it begs another, more difficult question: Why isn't
the women's health community talking about this? Cesarean section is far more
dangerous and debilitating than vaginal birth, and 1.2 million American women
now go through it each year. Fully half of first time mothers are induced into
labor, which adds significant pain and risk. A quarter of women who give birth
vaginally still get episiotomies (cutting the vaginal opening during labor),
though the practice has been debunked by research for years. As if to add
insult to injury, women who've previously given birth by cesarean are
systematically being refused vaginal birth, or VBAC (vaginal birth after
cesarean): about half of hospitals ban it, which
essentially tells women they have no choice but to submit to scheduled repeat surgery.
You might think that one of these issues would come up at the recent round table discussion on women's health at the White House , and yet you'd be wrong. In 90 minutes there was not one mention of the rising cesarean rate or the rising maternal death rate, nor of VBAC denials, nor of birth centers, nor home birth, nor any mention of midwives, nor were any midwifery organizations represented among the 25 participants. The only childbirth-related topic brought up was pre-term birth and access to care, but no question as to the quality of the care itself. "There hasn't been any healthcare reform agenda put out by any national women's groups that has embraced birth centers and midwives and evidenced-based maternity care as a prime element of health care for women," says Susan Jenkins.
