Delivering Affordable Health Care

Michelle Bartlett is not the typical Washington high-stakes health-care player. She's probably not on the radar of anyone in Congress or the Obama administration. Bartlett is a midwife in Idaho, but in the last few years, she's been trying her hand at lobbying. This came after a night spent in jail for using medication during a home birth she attended in 2000. Bartlett was the second midwife to be charged for this type of practice in Idaho, and thanks to her efforts, she will be the last in her state. "I've done a lot of hard things in my life, and giving birth was one of them," Bartlett says. "But giving birth to a law was really hard."

On April 1, Gov. C.L. "Butch" Otter of Idaho signed legislation allowing certified professional midwives (CPMs) like Bartlett to administer medication during births. Unlike certified nurse midwives who are able to practice in all 50 states and generally work in hospital settings alongside obstetricians, midwives like Bartlett are referred to as "direct entry" midwives, and practice exclusively outside of hospitals, mostly in homes or birth centers. These CPMs spend three to five years training and meet the standards for certification set by the North American Registry of Midwives.

Idaho's recent legislative decision is looking like a sign of a broader movement nationally for certified professional midwifery. Idaho is the 26th state to license CPMs and is also one of four states to have passed similar legislation since 2005, alongside Wisconsin, Virginia, and Utah. According to Katie Prown, campaign manager for The Big Push for Midwives, at least three other states have pending legislation, and a handful more look likely to pass similar laws in the next legislative session. Prown explains, "We're seeing that in state after state where the midwifery bills had been dead in committee for years, there is unprecedented progress."

State licensing fights may be the first step for these midwives, but it's not their last. Now they're turning their attention to the federal health-care reform debate, and a look at the maternity-related health-care costs quickly explains why. Childbirth is among the top five causes for hospitalization, and the No. 1 cause for women. According to Childbirth Connection, Cesarean section is the most common operating-room procedure, and in 2009 the C-section rate hit an all-time high according to the Centers for Disease Control and Prevention, at 31.8 percent of all births. These rates account, in part, for the increasing cost of maternity care in the U.S. Maternal and newborn charges totaled $86 billion in 2006, 45 percent of which was paid for by Medicaid. The federal government is already footing a huge portion of the U.S.' maternity-care bill, and these midwives think they can help reduce costs significantly, and not just for low-income women.

It isn't coincidental that we're seeing this kind of progress for CPMs during an economic downturn. Midwives like Bartlett are often the only option for pregnant women who are underinsured, as many in her state are. She's seen a growth in her midwifery practice in recent years, and many of the women who come to her fall between the gap of the privately insured and those who qualify for Medicaid. These women choose to enlist Bartlett's services (a bargain at around $3,000) rather than pay out of pocket for a hospital birth (around $8,500) or even the high deductible for their insurance plan.

Bartlett and her clients aren't the only ones who see the cost benefits of midwifery. David Anderson, economics professor at Centre College in Kentucky, has run the numbers and says that midwifery care could save us billions of dollars annually, without affecting quality of care (maybe even improving it). Anderson posits that if we increase the percentage of women giving birth out of hospital by 10 percent (currently at only 1 percent nationally) we could save close to $9 billion per year. He points to the difference in baseline costs for out-of-hospital birth -- a difference of more than $6,000 when comparing the average cost of a home birth to an in-hospital one. Another main cost reducer, according to Anderson, is the significantly lower rate of C-sections for out-of-hospital births.

It's not just the costs that are lower, according to these advocates. The outcomes are better too, which in turn, further lowers cost by reducing additional care needed by sick babies and mothers. Anderson adds that if CPMs are allowed to practice in all 50 states, competition will drive down prices for maternity care, since more women will have access to a low-cost alternative to hospital births.

Washington, one of the first states to license CPMs, now has an out-of-hospital birth rate twice the national average and has seen these claims of cost effectiveness come true. The most recent Department of Health cost-benefit analysis showed that licensed midwifery care in Washington saves the state $3.1 million every two years in Medicaid costs.

Even Bartlett has decided to continue her battle beyond Idaho. "Now I'm trying to jump on the federal bandwagon," Bartlett explains. But advocating for CPMs at the federal level in the middle of the debate over national health-care reform is not an easy task. Their education efforts are just barely beginning, and getting maternity care (and midwives) on the radar of health-care reform is proving difficult, despite the impressive statistics on potential cost saving. A coalition of six midwifery advocacy groups is focusing their efforts on one goal: getting CPMs included as eligible Medicaid providers within health-care reform legislation. They believe this is the most realistic ask and would expand access to CPMs for women on Medicaid, in addition to making the state-level battles much easier to fight.

Midwives like Bartlett may be turning their attention to the federal debate, but these efforts are just barely beginning. Maternity care is almost completely absent from all three of the health-care reform bills that are currently circulating through Congress, and the minor references that do exist don't mention CPMs at all. "The current bills overlook the maternity-care crisis," explains Brielle Epstein, a federal advocacy director with the Big Push for Midwives. "[They] also overlook the importance of non-physician providers." There is still time to get CPMs included in the final legislation, but they're likely to see some serious opposition if they are. Historically, the opposition faced by midwifery advocates has been fierce -- an extremely well-organized medical lobby that has the interests of obstetricians and hospitals in mind.

Home-birth advocates are also fighting against a strong societal belief that the hospital is the safest place for birth -- a belief that the medical profession has spent the better part of a century promoting. Beginning in the early 1900s, when the modern obstetrics profession was developed and birth in the hospital became standard practice, doctors have been working hard to convince women that hospital deliveries are the better option. This became institutionalized and legislated, with most states passing Medical Practice Acts in the 1950s that iterated exactly what type of providers could practice medicine and be licensed. In most states, this essentially made the practice of midwifery illegal.

The American Medical Association has long been an opponent of out-of-hospital birth. As a professional association tasked with protecting the business interests of its constituency (doctors), advocates say that the AMA sees midwives and out-of-hospital birth as a threat to its stronghold over maternity care in the U.S. Some argue CPMs don't have the proper training to be birth providers. Others argue that out-of-hospital birth (particularly home birth) is never safe. Still others refuse to take seriously the research touted by midwifery advocates that claims equal levels of safety and better outcomes for babies born out of the hospital.

Midwifery advocates say they have research on their side, and their recent legislative wins suggest that state policy-makers are beginning to agree. While the advocates see that being part of the federal health-care reform process is the logical next step, so far their efforts haven't seen much fruition. This may not be for their lack of trying -- the AMA is already at Obama's health-care reform table, and it has made its opposition to midwives and out-of-hospital birth clear. The advocates are keeping a positive attitude, though, and say their meetings with committee members and legislators are going well. "Everyone is at least intrigued by [CPMs]," Epstein says. "No one has been flat-out opposed." This may not seem like much, but for these new lobbyists, it's something.

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