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 [3] 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" [4] 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 [5] 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 [6] 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 [7] 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 [8], 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, [9] 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 [10] it, which
essentially tells women they have no choice [11]but to submit to scheduled repeat surgery.
You might think that one of these issues would come up at the recent round
table discussion [12] 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.
!pagebreak!
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 [13], The National Women's Law Center [14],
The Center for American Progress [15], Planned Parenthood [16], and the ACLU Reproductive
Rights Task Force [17] 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 [18], 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 [19] 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 [20] 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 [21] (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 [22] for women's health reform put out by the
Center for American Progress and Columbia University [23].
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" [24] 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 [25] and home birth [26], 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 [27] 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 [28] succeeded in getting birth-center Medicaid
eligibility into all the reform bills; and the Big Push for Midwives and MAMA
campaign [29] 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.