From The Field O C T O B E R 2 1 , 2 0 1 3 The Pregnant Elephant in the Room: The U.S. Maternity Care Crisis ROBIN HUTSON Executive Director, Foundation for the Advancement of Midwifery LAURIE FOSTER, CNM, MSN Board President, Foundation for the Advancement of Midwifery A healthy 29-year-old American woman arrives at the ence something vastly different. Why do American women hospital in labor. Her obstetrician does an exam; she is routinely get major abdominal surgery? What is driving the two centimeters dilated. When her labor does not maternity care crisis in the United States? Expensive and invasive progress, she is given Pitocin and put on a fetal monitor— medical interventions—designed to save lives in high-risk rendering her bed-ridden. Labor support is minimal. The situations—have become routine, rendering them harmful Pitocin escalates her contractions so she is given an epidural instead of helpful, and costing billions of unnecessary dollars. for the pain. The labor lags with the epidural, the Pitocin is increased, and subsequently the baby’s heart rate shows signs OUTCOMES/QUALITY of stress. A cesarean section is ordered, and the baby is Despite the high cost of maternity care, the United States has delivered surgically and sent to the nursery for observation. one of the worst rates of both infant and maternal death Breastfeeding is difficult, and the recovery is long. Her among industrialized nations. The maternal mortality rate prenatal care consisted of expensive testing, four ultrasounds, in the United States has doubled over 25 years, as has the and short 15-minute appointments with her obstetrician. cesarean section rate, which now exceeds 30 percent. The The care and delivery cost upwards of $35,000. World Health Organization states that a cesarean section rate A similar, healthy 29-year-old Dutch woman arrives at the above 15 percent has no added benefit to health outcomes hospital in labor. Her midwife does an exam; she is two cen- and constitutes unnecessary surgery (Gibbons et al. 2010). timeters dilated. Her midwife suggests she go home, take a The outcomes for women and babies of color are dramati- walk, and rest. She returns and is six centimeters dilated. Her cally worse, leading Amnesty International to place the United midwife provides encouragement, massage, and suggestions for States on a watch list for this human rights violation, docu- her laboring positions to decrease her pain. She gives birth mented in its 2010 report Deadly Delivery. African-American naturally to a healthy baby, and because they were never sepa- women are four times more likely than white women to die of rated, the baby begins breastfeeding immediately. A home childbirth related causes. The infant mortality rate among health nurse visits her every day for the first weeks. During her African Americans is three times that of whites, and pre-term prenatal care she has had basic testing, one ultrasound, and and low birth weight rates are double. educational and supportive prenatal visits. Her prenatal care and birth experience cost 4,500 Euros ($6,000), fully covered IMPLEMENTING THE SOLUTION by the Dutch health care system. The United States must improve outcomes and decrease costs. THE PREGNANT ELEPHANT IN THE ROOM: There is a clear solution: increase the percent of births THE CRISIS attended by midwives and employ the midwifery model of care as the evidence-based standard. Maternity and newborn care cost the United States over $50 bil- A critical difference when comparing the U.S. system to lion annually—the largest category of hospital costs for Medicaid countries with better outcomes is that midwives do not deliver and commercial insurers—yet the United States ranks 50th in the majority of American babies. In most European countries, the world for maternal mortality and 36th for neonatal mortality the standard is for all women to receive midwifery care; in the (Coeytaux et al. 2011; The World Bank 2012). In light of the United States only 10 percent do. changes taking place in the American health care system, what is The Cochrane Collaboration released a study in August 2013 being done to improve the quality of care, cost, and outcome of comparing various maternity care models; their results stated the most important medical event in human life? Even though in that the group receiving midwife-led care showed the greatest each scenario a “healthy baby” is the result, the mothers experi- benefits to mother and baby, including fewer interventions and fewer pre-term births. The low-tech, more personalized model attended by midwives; this number, however, is on the rise. of care offered by midwives where pregnancy is not treated as From 2004 to 2011, home births increased by 50 percent an illness, results in better outcomes for low-risk women and is nationally (Birkner 2013). Still, 98 percent of women continue delivered at lower costs (Sandall et al. 2013). to deliver in hospitals, and they deserve the highest quality care available. Our three funds believe that if we fully integrate the ADDRESSING DISPARITIES WITH midwifery model of care into U.S. hospitals—as do those MIDWIFERY CARE countries with superior results—we can improve outcomes, Midwifery care has proven to have a dramatic effect on the reduce costs, and decrease disparities. outcomes for minority women and their babies. One example in the District of Columbia is the Family Health and Birth For those interested in joining this affinity group or learning Center (FHBC), which provides midwifery care for African- more, contact Robin Hutson at robin@formidwifery.org. American families who are politically disfranchised and economically impoverished. After only five years, the percent- age of preterm births was 9 percent for women at the FHBC compared to 14.2 percent for the District generally. Similarly, the percentage of low birth weight infants was halved at the SOURCES FHBC compared to the wider District community (7 percent Amnesty International, Deadly Delivery: The Maternal Care versus 14.6 percent respectively) (FHBC 2007). Another example is Commonsense Childbirth, led by Crisis in the USA, <http://www.amnestyusa.org/sites/default/ midwife Jennie Joseph. In her Florida clinic she cares for a files/pdfs/deadlydelivery.pdf>, 2010. high-risk population using a unique midwifery model. She Birkner, Gabrielle, “Home Births on the Rise for New York has significantly reduced the number of preterm and low Families,” Wall Street Journal, August 25, 2013. birth weight babies born to her clients (Joseph 2013). Foundation for the Advancement of Midwifery (FAM) has Coeytaux, Francine, Debra Bingham, and Nan Strauss, supported Joseph’s work by funding opportunities for her to “Maternal Mortality in the United States: A Human Rights teach her method to other midwives. Failure,” Association of Reproductive Health Professionals, <http://www.arhp.org/publications-and-resources/ THE ROLE FOR HEALTH FUNDERS contraception-journal/march-2011>, March 2011. Three member funds recently created an affinity group for Family Health and Birth Center (FHBC), Briefing Statement to funders who recognize that increased access to midwifery is an the Committee on Health of the Council of the District of essential step in maternity care reform: the Health Foundation Columbia (Washington, DC: February 22, 2007). for Western and Central New York, The Transforming Birth Gibbons, Luz, José M. Belizán, Jeremy Lauer, et al., The Global Fund (a donor advised fund of the New Hampshire Charitable Numbers and Costs of Additionally Needed and Unnecessary Foundation), and FAM. There are many approaches for Caesarean Sections Performed per Year: Overuse as a Barrier to grantmakers to fund increased access to midwifery care. The Universal Coverage (Geneva, Switzerland: World Health Transforming Birth Fund has had a policy focus, funding blue- Organization, 2010). prints for this new direction in maternity care. The Health Foundation for Western and Central New York has funded Home Birth Consensus Summit (HBCS), “Common Ground community-based care to support the midwifery practices that Vision Statements,” <http://www.homebirthsummit.org/ serve specific populations vulnerable to poor outcomes. summits/vision/statements>, 2013. FAM supports policy, education, research, and certain Joseph, Jennie, Commonsense Childbirth, “Outcomes of the JJ direct care initiatives. As an example of its strategic invest- Way and Other Research,” <http://commonsensechildbirth.org/ ments, The Transforming Birth Fund and FAM funded the index.php/outcomes>, 2013. 2011 Homebirth Consensus Summit (HBCS), which included stakeholders in U.S. maternity care who historically Sandall, J., H. Soltani, S. Gates, et al., “Midwife-Led have a contentious relationship. The HBCS did not debate Continuity Models versus Other Models of Care for the idea of home birth, but convened a strategic conversation Childbearing Women,” <http://summaries.cochrane.org/ on how to best serve the families that fall between the two CD004667/midwife-led-continuity-models-versus-other- systems: those that intend to birth at home but transfer to a models-of-care-for-childbearing-women>, August 21, 2013. hospital for additional medical intervention. The World Bank, Level and Trends in Child Mortality. Estimates This facilitated summit opened unprecedented dialogue Developed by the United Nations Inter-Agency Group for Child and resulted in nine consensus statements. FAM is now Mortality Estimation (UNICEF, WHO, World Bank, UN DESA, funding the HBCS Regulation and Licensure Task Force, a UNPD). Data from 2008-2012, <http://data.worldbank.org/ working group moving to manifest one of the consensus indicator/SH.DYN.NMRT>, 2012. statements (HBCS 2013). Resources are small by comparison to many other funds, but this strategic investment has changed the conversation between maternity care providers. Views from the Field is offered by GIH as a forum Only 2 percent of all U.S. births are planned home births for health grantmakers to share insights and experiences. If you are interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.