How to Fix the “Travesty” of U.S. Maternity Care – And Ensure Women Have a Full Range of Choices

By Guest Contributor |

anna-fettby Anna Fett

“So, when am I going to get a grandbaby?”

We have not even been married a month and already my mother-in-law has begun peppering my husband and me with this loaded question.

Babies are still the furthest thing from my mind. I moved to Cambridge with big dreams of pursuing a master’s degree and then plowing onward toward doctoral studies. I know very few people who attempt graduate studies and motherhood simultaneously, and for me the former currently takes precedent over the latter.

Besides the occasional prodding from my family, I rarely think about becoming a mother — that is, until I happened to read a startling headline on the JAMA Forum that caught my attention: “Transforming the Costly Travesty of U.S. Maternity Care.”

My curiosity was piqued; while I knew there are problems in the healthcare system, I was unaware that maternity care in particular was suffering a “travesty.”

The article by Dr. Diana Mason begins by ranking the United States as 46th in the world on maternal mortality “with a rate that has doubled since 1987 and is twice that of 31 other nations.” I was shocked.

The fact that the United States could be so far behind other countries was disturbing, but even more troubling was my ignorance on this issue. How did I not know this? Why are we not all discussing the quality of maternity care?

Moreover, how could this be? — especially given the fact that maternal and newborn care is also the most costly reason for hospitalization in the United States.

My brain attempted to process this debacle. We are paying too much for maternal-newborn care without meeting the same standards of quality of many other countries in the world.

Even though pregnant women in America comprise “a largely healthy population that needs few procedures or technological interventions,” writes Mason, the system is set up to encourage unnecessary procedures, such as cesarean sections — “now the most common operating room procedure in the United States” — despite the fact that normal vaginal births cost 30 percent less.

Suddenly “travesty” did not seem such a stretch.

The goal of Mason’s article is to develop ways of improving maternal-newborn care while also reducing costs, which she believes can be done by shifting to the midwifery model of care. I admit hearing the term “midwifery” instantly conjured images of the Middle Ages for me, but in reality midwives still play prominent roles around the world, and in the United States there is a push to expand midwifery services.

There are now 250 birth centers that follow the model that “maternity services should be provided by certified and licensed midwives and family physicians,” while obstetricians should be reserved for “high-risk pregnancies.”

Maternity care at these facilities could be a much more cost effective option than hospitals if health insurance companies and Medicaid were required to pay “birth centers at 100% of the rate of hospitals for the same or equivalent codes, such as for normal vaginal deliveries,” writes Mason. Families have difficulty taking advantage of what would be a cheaper option because their insurance does not cover deliveries by family physicians or midwives.

As I absorbed this article, a deeper concern struck: The transformation that Mason envisions must also encompass the American way of thinking about maternity care. Instead of viewing the professional provider as the one who delivers a mother’s newborn, the midwifery framework holds that the mother gives birth “with the support of the professional” and “with physician and hospital back-up as needed.”

If we aligned our public policy with the midwifery framework, we could appreciate returning the power of choice to American mothers. Women should be able to decide where to give birth — in the hospital, birth center, or home — and they should be able to decide who will attend them: midwives, family physicians, or obstetricians.

But this can only happen after improving insurance and Medicaid coverage, implementing policies that allow women to choose among these options, and ensuring that midwives receive the education and protection they need, as Mason writes, to “practice to the full extent of their training.” Only by tackling the factors Mason raises can we ensure that women have the full range of choices they need to get the maternity care that is right for them and their family.

When, or even if, my husband and I decide to have children, it is a choice that we get to make when it is right for us — despite my mother-in-law’s best attempts at interference. When we have so many choices ahead of us in life, it seems obvious that we should also have options of where and how to receive maternity care.

I am now joining the ranks of those who want to make the transformation of U.S. maternity care a reality.

Anna Fett is a master of theological studies candidate at Harvard Divinity School with a focus in women and gender studies as well as Islamic studies. She will graduate in May 2014.

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7 Comments

  1. Lauren says:

    A very timely article. I spent ten years working as an independent midwife in New Zealand, one of the most progressive countries ,in my opinion for birth care. Thanks to our former Prime Minister Helen Clark who supported and helped orchestrate women centred care. For many pregnant women, they will be followed through the pregnancy by a qualified midwife. Midwives are able to prescribe, order tests, order scans, and identify deviations from the norm. If any medical concerns arise the LMC or Lead Maternity Carer will refer her to the appropriate specialist,or other practitioner ie physio.

    Midwives belong to a professional body, pay indemnity insurance and are paid by the government if they are self employed or by the district health board. During their pregnancy many healthy women will only see their midwife. It is in everyone’s interest for women to have normal outcomes. Women are cared for from early pregnancy until 4 weeks postpartum. The midwife will visit the new mother at home supporting breast feeding visiting frequently the first week and then weekly until mother and baby relationship are well established. In this model of care women are able to get to know their midwife well and the form a relationship and build a trust that definitely enhances the experience for mother, family and midwife too.

    ,

  2. Jaye Anne says:

    It is so great that you are considering these questions now! I was pregnant when I realized how screwy the system is and how to navigate it if I wanted a powerful birth. Fortunately, I ended up with great midwives and a beautiful birth. Thank you for this article.

  3. Jenn says:

    The most recent study shows that the midwifery led model of care provides no better outcome than any other model and is in fact at least as high in cost, according to NZ MoH figures. This is without consideration of the fixes needed to assist with some long term effects of vaginal birth – prolapsed bladder and hysterectomies, bladder and bowel incontinence, repair or reconstruction of the vaginal wall and rectum, sexual dysfunction or mental trauma. Costings in the USA would likely be similarly estimated if considered as a whole, though the issue there seems to be more one of ensuring training/registration/insurance of midwives is thorough and consistent over all states.

    The article by the Dr that this opinion piece is based on states: “The cost of maternal care for a vaginal birth is 30% lower than for a cesarean delivery. The Center for Healthcare Quality and Payment Reform has estimated that reducing the rate of US cesarean deliveries to the 15% recommended by the World Health Organization could save about $5 billion a year”. The WHO ‘recommendation’ is no longer expressed as a %. The 15% was withdrawn due to the realisation that it was unfounded and not based on evidence and replaced with, essentially, the recommendation that there should be as many ceasareans as deemed necessary by the professionals involved. The mere fact that this past and very much retired WHO “recommendation” is highlighted in this article shows that the information held within is at best outdated and at worst completely incorrect.

    http://www.aim.org.nz

  4. moto_librarian says:

    I think that you are falling for the lure of natural childbirth ideology, which asserts that birth is a “natural, normal” process, not a “medical condition.” The problem with this approach is that in the absence of modern obstetric advances, childbirth is the leading cause of death for women, and it kills many of their babies as well. You need only look at the horrifying death toll of childbirth in the developing world to see this borne out. Women there are dying from postpartum hemorrhages, lack of access to c-sections, and other things that we take for granted.

    The other problem is that childbirth is only “low-risk” in retrospect. While you can indeed be having a typical and healthy pregnancy, that can change in an instant. I know this on a personal level. I had a “textbook” unmedicated vaginal delivery with a certified nurse midwife in a hospital. As soon as the placenta was delivered, I began to hemorrhage. I had a cervical laceration, and the bleeding was not going to stop until I was stitched up in the operating room. Even with prompt care, I was on the verge of requiring a blood transfusion, and my recovery was long and painful. I will always be grateful to the midwife, nurses, and doctors that saved my life that day so I could live to mother my son.

    I would never have had a second child if there was no such thing as an epidural. My second birth was peaceful, and I had no pain, even when my son was crowning. I was present mentally, and I enjoyed the experience. Too often, this emphasis on birth “choices” is interpreted as actually giving women fewer choices by advocating for “natural” birth – e.g., no pain medications, lowering the c-section rate at any cost, etc. What you fail to realize is that most women prefer to have access to these interventions because they value a healthy mother and baby over ideology. I always here a lot of blathering about a 30% c-section rate, but this is the OVERALL rate for c-sections. The primary rate (i.e., for first-time mothers) is around 15-20%. Not every woman wants to have a VBAC, and some women would prefer to have a maternal request c-section over a vaginal birth. Too often, the risks of vaginal birth are completely ignored by NCB advocates. Tearing, incontinence, and prolapse are all potential consequences of vaginal birth, and they should not be downplayed.

    You may feel differently about this topic when you yourself are pregnant and discover how painful labor is for most women. In the meantime, I encourage you to educate yourself on the facts surrounding childbirth in this country, and to remember that our population is not particularly healthy to begin with.

  5. Dawn says:

    I’m thrilled to see such an article written by a young woman who has yet to have had a child. Where we are talking about natural vaginal birth or epidural birth, the fact is, out maternity care system needs improvement. The lack of evidence based care and dignity many woman experience is unacceptable. Anna, I have a feeling that you will be very interested in Improvingbirth dot org.

  6. Cristen says:

    Amen, sister. Thank you for writing this article! Keep at it.

    Entering the maternity care system three years ago with my first pregnancy was a shock and an education. As a healthy, low-risk woman, I saw three obstetricians and two midwives before finding someone who treated me like an intelligent human being with a capable body – even switching providers the day before I gave birth to avoid an unnecessary induction of labor.

    Let me clarify for the folks above: this has nothing to do with natural childbirth. Maybe in 1975, but not in 2014. This is about evidence-based care and safer, healthier births; reducing trauma and improving outcomes. It’s about getting the care we need when we need it – and not having it imposed upon us when we don’t. It’s about women making safer, more informed decisions about their own bodies and babies.

    It’s not even up for debate anymore whether or not women are receiving surgery (and other procedures) they don’t need and which increase risks to them and their babies. The variation in C-section rates in hospitals across the country is as much as 15-fold. In my own state, it’s 12% to 68%. Yep, we actually have three hospitals with C-section rates over 60%.

    Even the accrediting body for hospitals, the Joint Commission, has made lowering the C-section rate a priority: “The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section rates… There are no data that higher rates improve any outcomes, yet C-section rates continue to rise. Some hospitals now have C-section rates over 50%.” The Commission also points to “physician factors” as a driving force in this variation.

    Check out this table of routine birth practices vs. what the evidence shows:

    I encourage anyone who is interested in seeing a change to join other women and mothers at ImprovingBirth.org’s Facebook page:

    Anna, thanks again. So glad to see young women getting smart about maternity care :)

  7. I gave birth to a son in September of last year, VAVD. According to my medical records, I was only in the second stage of labor for 16 minutes. You can imagine my shock when the bill arrived with a $4,292 charge for “operating room services,” by far the largest charge on a bill that amounted to $16,442.37 for a VAVD and two-day hospital stay. I asked my provider about it since I obviously hadn’t had a c-section. He said that, after the vacuum had popped off once, they had called for the c-section team to get ready. $4,292 for what couldn’t have been more than 5-10 minutes of c-section prep that was ultimately not needed? Really? How can anybody think there isn’t something tragically broken in our maternity care system?

    I recently looked up the episiotomy rate in a few local hospitals, as reported by the LeapFrog Group:

    Evanston Hospital — 6.1%

    Highland Park Hospital (where I gave birth) — 15.5%

    Northwest Community Hospital (closest to where I live) — 22.8%

    Here are the c-section rates for those same hospitals:

    Evanston — 26%

    Highland Park — 31.4%

    NCH — 35.2%

    You’re probably thinking, “Well, maybe the hospitals with the higher rates handle more high-risk births.” And you’d be wrong. Evanston has a level 4 NICU while Highland Park and NCH are only level 3. So it’s Evanston that probably sees more high-risk births.

    I’m not an NCB-advocate. I don’t care what your birth preferences are. There’s nothing wrong with having an epidural or requesting other pain medications. There’s nothing wrong with requesting a c-section for no medical reason whatsoever, if that’s what you want.

    What I care about is that providers are pushing interventions that aren’t necessary with the result that things like c-sections and episiotomies are needlessly being performed. What I care about is that any woman who doesn’t want to jump on the Pitocin-amniotomy-epidural assembly line tends to have her birth preferences belittled by the staff. What I care about is that so many practices that are not based in evidence are flourishing, like routine continuous fetal monitoring and telling women they can’t eat in labor. And finally, I care that insurance companies will pay for a hospital birth with a c-section or an epidural, but they won’t pay for doula services or a birthing center birth or a home birth, even though those things cost so much less.

    This country is fond of the mantra “my baby, my body, my choice,” but that only seems to apply if you’re getting rid of the baby. Once you decide to keep it, it’s “shut up and do what your doctor and your insurance company tells you to do.”