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.

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?"

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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.

!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, 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,

Child Health Services Block Grant, reinstate birth centers as eligible for

Medicaid reimbursement (a Bush policy casualty), and

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.