It's a weekday night and I am headed to bed soon because I might be woken in the night to go to a birth. The birth, when it happens, will be with a young woman who—although she and her partner moved last month to another part of Washington State that has no local midwife—chose to come back to Seattle to stay with an aunt in order to have access to midwifery care. She wants the kind of birth where her chosen care providers and support people will be with her; where she will have privacy and intimacy; where she will be allowed to eat and drink to sustain her energy during the labor; she will be encouraged to be in whatever position feels comfortable to her, including finding comfort in a warm pool of water; and where she and her baby will be carefully monitored to make sure they are well and the labor is progressing normally.
She will be "allowed" to labor at her own pace without intervention, unless she asks for it—whether that takes just a few hours or many. She will be given information at each decision-making point; allowing her the ability to make her own educated choices about her care and her baby's. She and her partner will be supported to make this journey of labor together and she will come out the other side empowered and amazed at what her body can do. She'll know after that intense experience "if I can do that ... I can do anything!"
The state of Washington is picking up the tab for her care since she qualifies for Medicaid coverage. DSHS (Department of Health and Human Services) recognized early on, in a study about the "safety of home birth" in Washington [6], the benefits of Licensed Midwifery care. They halted the pilot program and started providing access to the services of Licensed Midwives as part of the Medicaid plan. What are some of the benefits? Quality care at low cost. Childbirth at home or at a birth center. Lowered rates of intervention, medication, and cesarean section. A higher rate of vaginal deliveries with no increase in adverse events for mothers and infants. There are no differences in birth outcomes, except, as some studies have noted [7], an increase in maternal satisfaction with the birth, and the care.
Unfortunately many women who are covered by Medicaid don't know it's an option to have a Licensed Midwife attend their birth at home or at a birth center. Even women for whom it may be more culturally appropriate to have a midwife may not know about their rights and options for childbirth; Washington is home to many low income, minority, immigrant and refugee women who might benefit from midwifery care. Fortunately for my client, a very young but educated white woman, she does have the skills and privilege to explore her options and make informed choices.
As much as I love my work—I am honored to be a part of one of the most intimate, challenging, moving moments in a woman's life—it's amazing to me that my midwifery partner and I are still in practice. Indeed, at only seven years in practice together, we are the second longest running midwifery partnership in Seattle. Although we are contracted with insurance companies and receive payment for our services, the costs of having a practice are high and the (financial) payoffs are low. I am still awaiting the decision of legislators in Washington to see if our annual licensing fee, currently the highest of any licensed professional in the entire state, will be stabilized at $500, or rise to the projected $3,000 or more next year. Every year we pay increasingly more for malpractice coverage. And insurance companies reimburse us at a similar rate as MDs. However, although an MD might attend the end stages of a labor or be on call so the labor nurse can consult with them about the management of the birth, a midwife will be at a woman's side for hours on end (without nursing staff or shift changes) in order to give continuous one-on-one labor support.
A San Francisco hospital executive recently described midwifery care as "boutique" care: too expensive and labor intensive to be provided in a hospital setting that serves mostly low-income patients. Is it a luxury to have a provider you trust who will be with you, encourage you in your most difficult moments, help keep your birth safe, give you information and choices about your care, regard you as the expert of your own body, and strive to honor and protect your experience? Rather than having this type of care as a right, women are often forced to sacrifice the right to safety, information and the fulfillment of their goals for birth in order to help the hospital run more smoothly and make the medical doctors less prone to liability. Perhaps normal birth is just not a money-making operation.
As hospital administrators urge their staff to step up production and minimize the risks of lawsuits, caesarean section rates are rising. A hospital in my community is approaching 40 percent. The hospital's Chief of Obstetrics told me "...now that we know c-sections are safer and cheaper, if you discount the personal satisfaction of a vaginal delivery, why have a vaginal birth?" Perhaps he meant it as a tongue-in-cheek statement about how medicine views a normal physiologic process as an accident (or a lawsuit) waiting to happen.
But it's more than just a normal physiologic process; it's a vulnerable, hard, beautiful transition in a woman's life. Doesn't she deserve to be supported, encouraged, and kept safe? Doesn't she deserve information about her body and this experience that will allow her to be an active participant in her care? No matter her culture, race, or income level? So why are midwifery practices closing around the United States at a time when many states are experiencing a shortage of obstetrical services? Why don't public policy makers, MD's, hospital administrators, midwives, and public health educators all agree to provide a team approach to meeting individual women's needs? I worry about the sustainability of my practice if I can't survive financially, or politically. I worry about the lack of access to safe, respectful maternity care for all women, especially if midwives and OB's are not supported to continue to provide quality, individualized care.
These issues are too much for one tired midwife to grapple with alone. I'd like this to be part of every woman's conversation with her friends, partners, health care providers, and above all, her legislators. It's part of a larger conversation about reproductive rights, health care rights, and basic human rights. All women should have their choice of care provider—in the setting of their choice, as appropriate to that individual person.