by Darcy N. Bryan
As a California obstetrician, I never interacted with nurse midwives, and could only nod my head in agreement when my colleagues voiced leeriness about working with them. After all, the buck stops with the doc, and we feared that midwives’ clinical decisions would lead to traumatic deliveries and bad outcomes. I’d heard the cautionary tales about messy transfers from birthing centers confronting the on-call OB.
Now that I’ve moved to Florida and shared 24-hour calls in hospital labor and delivery units with midwives — the types of shifts that leave us both rumpled and bleary eyed — I have come to respect, depend on, and celebrate these amazing professionals, along with the unique powers and perspective they bring to obstetrics.
Having spent most of my professional life as a doctor, caring for women and delivering their babies, why did it take so long for me to learn that in most cases, midwives provide legitimate and valuable care? Ultimately, it boils down to the U.S. health care system and how fragmented, expensive, and even harmful it can sometimes be for new moms and newborns.
The United States has the dubious distinction of ranking 60th in the world in maternal survival after childbirth. It’s the only developed nation with rising maternal mortality rates. U.S. childbirth is highly medicalized and often strips women of autonomy, respect and a sense of connectedness with the birthing process. Visits to the doctor are brief and usually interventional, consisting of ordering lab work, ultrasounds and monitoring, with minimal time for counseling and the nurturing care that a scared mom so often needs.
The midwife model of obstetrical care and the birthing centers where midwives often practice have a different, more holistic approach. The focus is communal and relational, with more emphasis on wellbeing and psychosocial support. Community birth center deliveries are typically one-half to one-third the cost of hospital births.
A 2016 Cochrane review, among many other studies, show that midwives provide high-quality, affordable obstetrical care for low-risk pregnancies, and their management of pregnancy often leads to fewer episiotomies, instrumental births and C-section deliveries. Clearly, midwives are getting some important things right.
What prevents this high-quality, high-value approach to obstetrics from being ubiquitous in the United States, as it is in England and other developed countries? America’s regulatory and third-party-payer environment.
Strong evidence supports interprofessional, collaborative practice models between doctors and hospitals and nurse midwives and community birthing centers. However, U.S. birth centers where midwives work are often forced to operate in isolation, with variable quality and accreditation. The midwife-birth center model of care is hard to effectively expand across the country primarily due to a lack of supportive state policies, overly strict limitations to which tasks midwives can perform, and barriers to adequate reimbursement for obstetrical services. In some states, midwife-attended births are as low as 0.4%. Most women with low-risk pregnancies have little alternative to delivery in the expensive, medicalized environment of the hospital.
How might women in the United States have more choice over the management of their pregnancies and receive less expensive care?
The first step is fostering professional collegiality between physicians and nurse midwives. Each bring something complementary to the table. Midwives, obstetricians and practice administrators must come together in their professional organizations and reach consensus on national guidelines ensuring the best evidence-based care with respect to hospital and birth center deliveries. Community birth centers and hospitals also need to establish collaboration agreements facilitating transfer to higher-order obstetrical care in the rare case of an obstetrical emergency.
Additionally, state laws need to be made more favorable to autonomous practice by nurse midwives. We must remove unnecessary restrictions on the services they provide — restrictions that in turn lead to higher costs for new mothers and the loss of continuity of care throughout pregnancies. Birth centers should also be exempted from certificate-of-need laws — a proven failure of a state policy that significantly reduces the emergence of new birth centers into the market.
Women suffer from a lack of options when it comes to obstetrical care. Often, they pay too much and get too little in terms of quality, value and personal care. Supporting the nurse midwife and community birth center model of care for low-risk pregnancies, and allowing it to better integrate with our doctors and hospitals, will give women the freedom of choice they deserve.
