America is overspending and under-serving women and families. The problem is not access to care; it is the care itself.

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.

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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.