This site has moved! Please visit the new blog at


Midwives Deliver - LA Times Article

Midwives deliver

America needs better birth care, and midwives can deliver it.

By Jennifer Block 
December 24, 2008

Some healthcare trivia: In the United States, what is the No. 1 reason people are admitted to the hospital? Not diabetes, not heart attack, not stroke. The answer is something that isn't even a disease: childbirth.

Not only is childbirth the most common reason for a hospital stay -- more than 4 million American women give birth each year -- it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation's maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

But cost hasn't translated into quality. We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison. Last month, the March of Dimes gave the country a "D" on its prematurity report card; California got a "C," but 18 other states and the District of Columbia, where 15.9% of babies are born too early, failed entirely.

The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.

In short, we are overspending and under-serving women and families. If the United States is serious about health reform, we need to begin, well, at the beginning.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices. They are inducing and speeding up far too many labors and reaching too quickly for the scalpel: Nearly one-third of births are now by caesarean section, more than twice what the World Health Organization has documented is a safe rate. In fact, the report found that the most common billable maternity procedures -- continuous electronic fetal monitoring, for instance -- have no clear benefit when used routinely.

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it's better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.

The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Wash- ington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%. Imagine if hospitals started promoting best practices: giving women one-on-one, continuous support, promoting movement and water immersion for pain relief, and reducing the use of labor stimulants and labor induction. The C-section rate would plummet, as would related infections, hemorrhages, neonatal intensive care admissions and deaths. And the country could save some serious cash. The joint Milbank report conservatively estimates savings of $2.5 billion a year if the caesarean rate were brought down to 15%.

To be frank, the U.S. maternity care system needs to be turned upside down. Midwives should be caring for the majority of pregnant women, and physicians should continue to handle high-risk cases, complications and emergencies. This is the division of labor, so to speak, that you find in the countries that spend less but get more.

In those countries, a persistent public health concern is a midwife shortage. In the U.S., we don't have similar regard for midwives or their model of care. Hospitals frequently shut down nurse-midwifery practices because they don't bring in enough revenue. And although certified nurse midwives are eligible providers under federal Medicaid law and mandated for reimbursement, certified professional midwives -- who are trained in out-of-hospital birth care -- are not. In several state legislatures, they are fighting simply to be licensed, legal healthcare providers. (Californians are lucky -- certified professional midwives are licensed, and Medi-Cal covers out-of-hospital birth.)

Barack Obama could be, among so many other firsts, the first birth-friendly president. How about a Midwife Corps to recruit and train the thousands of new midwives we'll need? How about federal funding to create hundreds of new birth centers? How about an ad campaign to educate women about optimal birth?

America needs better birth care, and midwives can deliver it.

Jennifer Block is the author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care."

1 comment:

Courtney said...

Interested in what people have to say? Comments taken from the LA Times site:

1. CPM education does engage in modern research and training can be (if you get it from somewhere reputable) QUITE adequate. Why do you think midwives see fewer deaths, interventions and complications than doctors do? CPM's can detect illnesses such as pre-eclampsia well in time to refer a high risk patient to an OB/GYN for care. Birth needs to be taken out of the hospital and put back into the hands of women who are more than capable of delivering them. Amen to this article, indeed! Say goodbye to the fear-mongering that has lead women to resent birth and flock to hospitals in "need" of drugs and interventions!
Submitted by: Robbin
1:47 PM PST, December 24, 2008

2. "Obstetrician" cites the inclusion of high risk prematures as invalidating comparisons with perinatal mortality rates of other countries, yet an increasing proportion of these preterm (especially late preterm) births have iatrogenic origins: "elective" labor inductions and scheduled cesareans, including cesareans for twins and breeches that elsewhere are born vaginally: and these interventions carry risks of their own. A recent study found: that late preterm babies “are more than three times as likely to be diagnosed with cerebral palsy than full-term babies, and have an increased risk for developmental delay or mental retardation.”
Submitted by: Prenatal/perinatal researcher
1:46 PM PST, December 24, 2008

3. "Concerned Physician" is regurgitating old, tired and invalid arguments that have been offered by obstetricians and OB-wanna-be's among family physicians for at least a century. The fact remains that countries in which midwives and/or family physicians are the primary caregivers with OB care only for high-risk and emergent problems outcomes are better (and women are more empowered in their birthing experiences). It is unfortunate that the U.S. is almost unique in the adversarial relationship between OBs and midwives (and even with family physicians) where elsewhere these relationships are far more collaborative and mutually supportive.
Submitted by: Prenatal/perinatal researcher
1:36 PM PST, December 24, 2008

4. Thanks for the fantastic article! I am looking forward to having a home birth with a CPM this August. I feel very confident in her level of training and experience. Post bachelor's degree, she attended a 3 year midwifery program and attended over 100 births BEFORE receiving her license and certification. I know I will be much more comfortable with this level of experience and expertise dealing with normal and natural childbirth, than I would be at a hospital where interventions are regularly recommended. Of course, a hospital will be close by if for some reason medical intervention becomes necessary.
Submitted by: Marie
1:20 PM PST, December 24, 2008

5. Unfortunately, conditions will probably have to get worse before they get better. For the sake of the women of this country, I hope not. Great article, Ms. Block.
Submitted by: Unnecesarean
12:57 PM PST, December 24, 2008

6. Unmedicated "natural"childbirth is not for everyone. Just because a woman opts for medicine to assist her or delivers via c-section doesn't mean the childbirth experience is any less meaningful to her! Sometimes the choices we make are in the best interest of the child and the mother. I'm a little tired of people's attitude that unless you deliver "their" way, you didn't do it right. Tell me, does that mean that unless you conceive "naturally" it's not right either?
Submitted by: C-Section Mom
12:57 PM PST, December 24, 2008

7. I'm getting really tired of the pompous way in which obstetricians scoff at the experience of CPM's. Have they ever heard of a midwife named Ina May Gaskin? Have they ever used the Gaskin Maneuver? The difference is that midwives are experienced in normal birth and OB's are experienced in TREATING birth, so they rarely EXPERIENCE what normal birth should be like. Here is a story of a local CPM and her journey to becoming an excellent midwife. You tell me what OB resident has more hands on experience than this with as much success as this midwife had. Here is the link:
Submitted by: Stephanie
12:46 PM PST, December 24, 2008

8. The education of the CPM has been evaluated as excellent by the states that license CPMs. These states have overseen the practice of licensed CPMs for many years, and are satisfied that the CPM can recognizing and handle emergencies. Research quoted by the physician groups also inclues unplanned and unattended births out of the hospital. Research regarding outcomes for out-of-hospital births planned and attended by CPMs proves the safety of this option with far fewer cesareans and inductions.
Submitted by: Concerned CPM

12:36 PM PST, December 24, 2008
9. The bottom line is that we have decades of solid medical literature supporting the safety and cost-effectiveness of skilled midwife attended births at home, which CPMS are. When discussing "evidence-based care" let's not overlook the clear double standard. Obstetricians are not required to adhere to evidence-based practices, and in general, they do not. All one has to do is look at the trends in obstetrical practice over the years, culminating with today's indefensible cesarean rates.
Submitted by: Erin Ellis
12:01 PM PST, December 24, 2008

10. An ad campaign about "optimal" birth? What condescending, sexist garbage. We're already given about a gazillion messages a day about all the various ways our bodies can be a failure unless we anxiously do a ton of difficult and energy-sapping things. So while it's very trendy now to extend this language of personal failure-avoidance to childbirth -- if you're a middle-class white woman -- but it's also very sexist. As is the notion that women's health is a good thing to save money on because, hey, they're just women, right? They like to suffer.
Submitted by: Trixie Mae
11:54 AM PST, December 24, 2008

10. Thank you Ms. Block for laying out the "painful truth" of our maternity care system. The rising cesarean rates have not translated into better outcomes for mothers or babies; the only way this will stop is when women demand better care. Certified Professional Midwives have 3-5 years of training, pass a national exam, and are experts in out-of-hospital birth and low-risk pregnancy. The research on CPMs proves their excellent outcomes. And in these difficult economic times, taxpayers should not have to pay for this gross overuse of non-evidence-based technology in the form of unnecessary interventions and cesareans. Women deserve better!
Submitted by: Wendy

11:53 AM PST, December 24, 2008
12. CPMs are far from lay midwives. They have extensive training in out-of-hospital birth. Their main focus is supporting normal birth. They are experts at recognizing when things aren't normal and transferring care when necessary. Their mortality outcomes for mothers and babies at home births are similar to low-risk women giving birth in hospitals. The big difference is these midwives prevent many birth injuries and are great at promoting breastfeeding. I agree increasing access to the Midwives Model of Care in hospitals, birth centers and homes would go a long way towards fixing our maternity care system...and boy does it need it!
Submitted by: Mom for Midwives
11:49 AM PST, December 24, 2008

13. One week ago my daughter gave birth to a little girl. One minute after the birth, my daughter was fighting for her life with an amniotic embolism. It is a very rare complication and none of the 12 doctors who responded to the code had ever seen it before. By God's grace and their skill, she came through, but she is one of the few. I wonder what would have happened had she not been in a hospital setting. We might be making funeral arrangements rather than rejoicing in our Christmas miracle.
Submitted by: Mary
11:31 AM PST, December 24, 2008

14. It should be possible to have lower intervention births in hospitals (somewhere between midwifery care and procedurally centered care). Usually family physicians tread that middle ground of less interventional care which is still provided in hospital where emergencies can be addressed rapidly.
Submitted by: Family Physician
11:24 AM PST, December 24, 2008

15. I understand the Concerned Physician's concern. I think there should be midwife schools for people to go to. Their focus would be specifically on all the situations that do come up. They would be required to observe so many labors etc before they could be a licensed midwife. But the idea that they have to be a nurse before becoming a midwife is not necessary in my opinion. I will be having a CNM attending my homebirth provided that there are not any labors going on at the hospital she works at.
Submitted by: Iowa Mom
11:13 AM PST, December 24, 2008

16. Who says we only need hospitals for diseases? My wife compares a hospital to a seat belt. It won't be as comfortable as a home birth, but it will save you in an emergency. Safety is our number one reason for choosing a hospital birth. The mortality rate is twice as high for home births as for hospitals. Look it up, because I can't post a link. That means that if you raised the rate of home births from 1% as the article suggests, you'd be killing more babies and mothers. Irresponsible article.
Submitted by: Expectant father
10:54 AM PST, December 24, 2008

17. Comment 4 is pretty entertaining; why is it not ok for Childbirth Connection to promote midwifery but ok for ACOG to promote obstetrics? Is ACOG supposed to be impartial? If you want to know who is telling the truth, then look at the best practice studies; ACOG cannot refute any of the stats Block cites. They're just protecting their revenue and trying to spread fear. Research shows less intervention is safer overall. If you dispute that, then show us the research that backs you up.
Submitted by: JB
10:11 AM PST, December 24, 2008

18. Excellent article! The medical establishment has fought mid-wifery for years to keep their monopoly on child birth sacred. I hope one day midwives in America will be considered the first choice for a woman's maternity health, not some crazy hippie alternative idea. I hope Obama will make this a piece of his agenda, for the sake of all the healthy mom's and babies in America.
Submitted by: Noel
10:08 AM PST, December 24, 2008

19. CPM education and training relies on a discredited theory of preeclampsia and never engages modern research. Until CPM training is adequate, why should states trust them to detect a deadly medical condition?
Submitted by: Caryn
9:52 AM PST, December 24, 2008

20. I have one hospital birth and two homebirths under my belt and all I can say is amen.
Submitted by: Indie
8:59 AM PST, December 24, 2008

21. The article is well-written but not exactly true to the actual situation. For example, let's call the "certified professional midwife" what it really represents...a lay person with minimal medical training and little experience at handling complications which may arise at the blink of an eye and for which the lay person is ill-equipped.
Submitted by: Concerned Physician
8:30 AM PST, December 24, 2008

22. The report does make some good points, but needs to be evaluated in the proper light. Childbirth Connections is entirely run and operated by and for the advancement of Midwives, a definite bias. Their conclusions somehow don't correlate well with National studies reported by the American College of OB-GYN. Additionally, one has to understand the perinatal mortality rates to compare like situations...the US includes all births and many other nations only include term births, excluding the high risk prematures.
Submitted by: Obstetrician
8:27 AM PST, December 24, 2008

23. Thank you, Jennifer Block, for getting this message out. It may put a lot of OBs on the defensive, but as you've shown us, they unfortunately have a lot to defend. As women begin to question all of the "routine" practices performed chiefly to protect the financial and professional interests of doctors and hospitals, the days of evidence-free practice are thankfully coming to a close.
Submitted by: ConcernedCitizen
8:03 AM PST, December 24, 2008