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.

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THE PREGNANT ELEPHANT IN THE ROOM

Early in 2008, long before Obama was even the Democratic nominee for President, the women's health community began organizing in anticipation of a new administration. On the advice of former Clinton advisors, groups like The National Partnership for Women and Families, The National Women's Law Center, The Center for American Progress, Planned Parenthood, and the ACLU Reproductive Rights Task Force formed a coalition to hammer out what it would ask for from the new administration.

"With Clinton, it was all thrown together very last minute," says Lisa Summers, who was with the National Partnership for Women and Families at the time. "We were told it would behoove the reproductive rights community to come together as a coalition so when the new president is elected we'd be ready to go to the transition team and say, This is what we want." The coalition was unprecedented.

At the same time, the birth community was organizing like never before, with the launch of The Big Push for Midwives, not to mention the growth of hundreds of local consciousness raising groups and steady DVD sales of The Business of Being Born, with national media coverage of a rising demand for midwife-attended home birth. The Big Push has so far persuaded several legislatures to license and regulate providers who had been previously considered criminals, and they've got active or pending legislation in 18 states.

Their success is thanks in large part to grassroots organizing, and to organizing across the abortion divide. "In Wisconsin we had a pro-life legislator from a rural part of the state introduce our legislation and one of the most liberal pro-choice senators from Milwaukee sign on to support it," says Katie Prown of the Big Push. In Missouri, it was the hard-right anti-abortion state senator John Loudon who snuck pro-midwife language into a bill.

Obama wants a common ground issue? This is it.

By early spring, the coalition of women's health groups had done initial brainstorming and divided into issue areas. One was "healthy pregnancies." Summers, a certified nurse midwife who had served as a director of the American College of Nurse Midwives, was delighted to see this and immediately joined the group. Coming from the provider community, Summers had a different perspective than the other members, most of whom had backgrounds in reproductive rights law, with one exception: a lobbyist for the American College of Obstetricians and Gynecologists. Summers offered to reach out to groups like Childbirth Connection, ACNM, and AWHONN, the organization for obstetric and neonatal nurses, so more stakeholders could have input. The National Advocates for Pregnant Women and the Big Push connected with the group as well.

The Big Push promptly sent a detailed memo that called for inclusion of Certified Professional Midwives (CPMs) as Medicaid providers, an investigation into "the frightening increase in cesarean surgery rates and hospital bans on VBAC," and stronger federal support for breastfeeding, among other specific suggestions for federal and administrative action. "Ultimately, midwifery, home birth, and birth centers must be included in whatever healthcare reform plan is enacted," wrote the Big Push, "but these interim steps to include all midwives and birth centers in Medicaid/Medicare are greatly needed. Approximately one-half of all women giving birth are eligible for Medicaid."

This was no small point, even then, in terms of cost savings. Part of what's sapping Medicaid funds are cesareans and neonatal intensive care admissions; the need for both of these procedures can be reduced through increased access to midwives. "The irony is that most women whose births are being paid for by taxpayers are being denied this option," Katie Prown points out.

The final document put out by the coalition, "Advancing Reproductive Rights and Health in a New Administration," which was presented to the Obama-Biden Transition Team, includes "Support healthy pregnancies" as one of eight major goals, with three specific recommendations:

• boost funding for the Maternal and Child Health Services Block Grant,
• reinstate birth centers as eligible for Medicaid reimbursement (a Bush policy casualty), and
• end the shackling of incarcerated women during labor.

But there is no mention of CPMs (or any midwives), the cesarean section rate, VBAC access, or home birth, or any overarching statement on the sorry state of U.S. maternity care in general. The same is true of subsequent blueprints for women's health reform put out by the Center for American Progress and Columbia University.

For birth advocates, the outcome was disappointing. "I was thinking about all the policies that have driven the over-medicalization of childbirth," says Summers.

"The payment system rewards providers for intervention and makes it difficult to have an out of hospital birth. And it's the workforce decisions that have led us to have tens of thousands of specialists and six thousand midwives. The government funds the vast majority of healthcare education, and it is disproportionately spent on physician education."

The disappointment notwithstanding, it wasn't unexpected.

The American College of Obstetricians and Gynecologists has what it calls a "longstanding opposition" to home birth and what it terms "lay" midwives, by which it means any midwife who is not also a nurse. Even in response to growing interest and attention to CPMs and home birth, the organization has only dug its heels in deeper. "ACOG does not support programs that advocate for, or individuals who provide, home births," says its 2007 statement on the subject. In Missouri, the local physician group tried mightily to block the CPM legislation, even suing the state over it (and losing). ACOG argues that the issue is safety, though the research suggests that for healthy women, planned home birth with a CPM is as safe as a planned hospital birth, if not safer because of the reduced likelihood of potentially harmful interventions. ACOG has also remained neutral on the rise in cesarean section, and its policies are directly responsible for the de facto VBAC ban.

Naturally, during the meetings leading up to the blueprint, the ACOG lobbyist was going to object to any recommendations that would expand the pool and power of midwives or increase access to home birth. What's perhaps interesting is that the group listened. "It was pretty clear that anything contentious wasn't going to go anywhere," says Summers. "The lobbyist didn't have to say much, and the group really needed ACOG there, because people on the Hill would say, 'Well, what do the OB/GYNs think?'"

!pagebreak! REPRODUCTIVE JUSTICE?

Of course, politicians aren't necessarily asking the right questions, but neither are the traditional allies of women's health, perhaps because they have historically been focused on contraception and abortion, to the exclusion of other related matters, such as wanted pregnancies and childbirth. Though the "healthy pregnancies" group was charged with naming top national maternity care priorities for the new administration, its members came to the table knowing very little about it.

"There was a learning curve," says Jessica Arons of the Center for American Progress, who was part of the group. Amy Allina of the National Women's Health Network also served on the group and felt the same. "Most of the groups who where involved don't work on childbirth issues," she says, and the goals that made the final cut reflected it.  Unshackling imprisoned women while they're in labor is a no-brainer. The concept of expanding midwifery care takes longer to digest.

On top of the learning curve, there's brand loyalty. "For the abortion rights community, doctors are our heroes," says Jessica Arons. "Whereas for the birthing rights community, the medical establishment is driven by malpractice insurance concerns, and the bottom line of for-profit hospitals, and moving to C-sections more quickly because they're more expedient, and all sorts of disincentives to providing care that's best for women.  So there's a tension there."

There's also a deeper, ideological hurdle. From the perspective of abortion rights advocates, medicine and technology are good--they guarantee reproductive freedom--and physicians who provide abortions protect women from harm. The goal is to achieve broader access to care.

From the perspective of birthing rights advocates, medicine and technology are overused and cause harm, and the goal is to protect women from unnecessary use of technology during labor and delivery. Reproductive freedom is further secured by expanding access to midwives and providing support for physiological birth.  With abortion, there's no question as to the standard of care; with birth, it's the care itself that needs questioning.

Arons says that maternity care issues have been increasingly on the feminist radar, especially in recent years as the reproductive rights movement has evolved into a movement for "reproductive justice." In building the pre-Obama women's health coalition, "we wanted to show a commitment to a wider set of issues, including pregnancy and birthing rights," she says.

"I think most of us recognize that a woman's ability to have a home birth, or a midwife assisted birth, or being able to say no to a C-section, that all of those are clearly related to her ability to decide whether to have an abortion. It's all within the same bundle of rights--to autonomy and self determination and informed consent and privacy."

But birth advocates are frustrated that they don't have more support from groups they perceive as natural allies. "We're not hearing a word from anyone publicly that birth is an issue that the Democratic Party should embrace," says Susan Jenkins, which seems like a tactical error as much as an inconsistency. Eighty-four percent of American women experience childbirth, more than 4 million a year. "Making changes in the way birthing care is handled in the U.S. would be one step that can have an immediate impact on a huge number of American women," says Jenkins.  "This could be a huge unifying factor for women across the political spectrum." But reproductive rights groups worry about "issue creep," that to expand the agenda to include issues like the cesarean rate or midwives could water down their effectiveness in preserving abortion rights.

To be fair, the birth community hasn't necessarily organized itself for optimal influence. Some of the maternity care groups that were invited to the "healthy pregnancies" meetings declined the invitation. A blueprint is due out from the Childbirth Connection's symposium, but not until late this year. In Washington, the American Association of Birth Centers succeeded in getting birth-center Medicaid eligibility into all the reform bills; and the Big Push for Midwives and MAMA campaign are undoubtedly creating buzz about the potential cost and health savings of midwives and out-of-hospital birth. But each is doing so separately, without the power of a coalition.  "There's a long list of groups that care about these issues," says Lisa Summers. "But there's never been an effective coalition for maternity care in DC."  Which raises another question: even if these groups could  join forces behind one blueprint, could it stand up to ACOG?

ACOG wields tremendous authority in Washington. And while it can be counted on to protect women's right to terminate a pregnancy, the group is actively trying to limit women's rights in choosing how, where, and with whom they give birth, and actively opposing policy changes that would directly benefit women and their families. It's likely that the coalition of women's health groups didn't anticipate the politics involved when it organized the "healthy pregnancies" team. It certainly put these feminist groups in the awkward position of facilitating what could be considered some very "un-feminist" advocacy.

"Reproductive justice is the recognition that all women--not just those ending their pregnancies, but also those who decide to go to term--need to be protected from punitive, ineffective, and unhealthy policies," says Lynn Paltrow of the National Advocates for Pregnant Women. "To advance policies that are protecting pregnant women who are going to term advances reproductive justice." The flip side, of course, is that to acquiesce to policies that harm pregnant women undermines it.

That said, the coalition itself is a huge achievement, and the fact that pregnancy and birth issues made it into the  blueprint represents a major victory for birth advocates. But what now? Now that this country is trying to envision a more just and economical health care system, and the women's health community is positioned to influence its development? It would seem that if the reproductive justice movement recognizes that birthing rights are cut from the same cloth as abortion rights, then it should be working harder for them. And that means, for starters, reconciling its conflicting interests with ACOG. Perhaps it's not so different than a woman standing up to her doctor: she risks being branded "difficult," but in the end, it's her body, her choice.