What To Expect When You’re Expecting   Leave a comment

Both of my children were born outside of the hospital in a direct-entry midwifery center. Direct-entry midwives, while licensed by the state, are not medical personnel. The midwife center we used has an infant and mother mortality rate of 1 in nearly 30 years of practice/

Alaska’s Medicaid system has covered direct-entry midwife deliveries for nearly 20 years, but that’s a rare thing in the United States, which has the worst rate of maternal deaths in the developed world, according to NPR. You didn’t know that? You would have thought one of the wealthiest and most technologically advanced countries in the world wouldn’t have a high maternal death rate. Yeah, me too.

Not too long ago, someone who wants universal health care insisted it was because of the inadequacy of our medical coverage that these women and their children are dying.

Image result for image of maternity wardNo, not really. Some of the deaths are attributable to poor maternal health – America leads the developed nations in incidents of gestational diabetes. We like to eat and many women view pregnancy as an excuse to chow down. We also smoke and drink while pregnant, despite ad campaigns imploring us not to. But really, the biggest part of the problem is due to high rates of medical invention.

The US medical care system, particularly surrounding pregnancy and delivery, is very interventionist, harming some of our most fundamental rights, including the right to control what happens to our bodies.

A typical American woman (98%) giving birth has a 40% chance of being covered by Medicaid, but the other 60% are usually covered by private insurance. The in-network provider is almost always an obstetrician and the care setting is almost always a hospital.

What happens in that hospital?

  • More than 40% of these mothers will have their labor chemically induced
  • More than 30% of those induced mothers will end up with a cesarean section.
  • Many more will be hooked up to machines and monitored, prevented from moving.
  • Food and water will be withheld during the labor
  • Most, if not all will be subjected to vaginal exams, electronic monitors, and other invasions of their bodies they don’t meaningfully consent to.

Most birthing women have little understanding of the risks and benefits of any of these procedures. They’re told it is for her or her baby’s benefit, but they’re a little busy at the time, so any risks are generally ignored. Yes, all these restrictions and invasions of the mother’s body are done ostensibly for the sake of hers and the baby’s health, but no medical reason exists for this level of intervention for most of these women. The vast majority of childbirths could happen as or even more safely if the mother were able to move around, eat, drink, and avoid invasive interventions.

Why Can’t American Women Use Hospital Alternatives for Childbirth?

Alternatives do exist  that lower intervention rates, lower costs, and provide more satisfactory care. These alternatives include freestanding birth centers (both direct-entry and nurse-midwife) and home births. Many European countries use these options as a foundational part of maternity care with great success. So why don’t we here in America?

Most American women cannot take advantage of these options because:

  • they do not know they exist
  • insurance does not cover them
  • they don’t exist in their area
  • a century of propaganda surrounding birth has effectively convinced women that anything but the hospital will result in death of themselves or their baby

If all this hospitalization and treatment actually helped keep women and babies safe, maybe the economic and human costs would be worth it. But it doesn’t, and they aren’t.

So why do American women give birth like this? What the average new mother does not know is that her choices surrounding how her baby is delivered and how her body is treated during labor and delivery are limited by a tangle of regulations and laws.

Regulations Push Out Entrepreneurial Midwives and Obstetricians

In most states, birth centers must go through a Certificate of Need (CON) process in which they must ask permission from hospitals (their direct competitors) to enter the market. Entrepreneurial midwives and obstetricians must pay tens, sometimes hundreds, of thousands of dollars in application and legal fees to navigate the CON process.

In New York State, entrepreneurs must already have their space rented before they start the CON process, which can itself take a year, thus forcing them to pay rent on an empty facility while they ask permission of their direct competitors to enter the market. That permission is frequently denied. Additonally, most states legally require birth centers to have a written consulting agreement with a physician. Such agreements increase physician malpractice insurance rates, so many are unwilling to sign such agreements.

Birth centers must also enter written agreements with hospitals to transfer their patients in case of an emergency, even though hospitals are already mandated by law to treat anyone who shows up in need. Birth centers cannot operate without these consultation and transfer agreements.

Doctors and hospitals can pull out of an agreement at any time, which means birth centers are at the total mercy of their direct competitors not only to enter the market but to stay in business, even if they are financially successful and providing high quality care.

The regulatory tangle providers find themselves in, means that, while 4 million women give birth in the United States every year, only around 300 birth centers exist to provide out-of-hospital care. Meanwhile, hospitals in many rural areas are closing their maternity wards, leaving women to drive many miles while in labor to find adequate facilities to deliver their babies, which puts themselves and their babies at risk.

How Medicaid Favors Hospital Births

Until recently, Medicaid did not reimburse patients for using birth centers at all, and now that it does, some states’ reimbursement rates are laughable. Many birth centers do not accept Medicaid at all because the reimbursement rates are so low that they threaten the facility’s continued existence. Here in Alaska, which has been covering birth center births for a couple of decades, the reimbursement rate is considerably less than for hospitals, but at least in the range of sustainability, but in states like New Jersey, reimbursement is as low as $250 per birth for care that costs birth centers $2000 or more to provide. For comparison, Medicaid reimburses hospitals for the exact same birth at nearly 30 times that rate (an average of $7,000). Government insurers are therefore paying more for women to receive lower quality care.

Yes, hospitals reimbursement rates reflect complicated births as well as uncomplicated deliveries, but we should acknowledge that such a great difference is indicative of government reimbursement policies that are fundamentally broken. Because Medicaid payment rates do not clearly track or relate to the care being provided or its quality, they create dramatic access barriers to higher quality care.

Barriers to Home Birth

Some women decide that in order to get the birth experience they want, they will opt out of the system altogether, paying for birth out of pocket at home. That seems like a reasonable exertion of free choice. Your body, your baby. Not so much. Government intervention doesn’t stop at the hospital doors. Women in many states who want to give birth at home may find that there are no legal providers to assist them. Until October 2017, home birth with a certified nurse midwife was illegal in Alabama – any midwife who attempted to assist a woman in labor was subject to criminal prosecution. In still other states, birthing mothers who seek an alternative practitioner are limited to certified nurse midwives, who almost always operate in hospitals or in birth centers attached to hospitals that are almost as medical as hospitals themselves.

So What’s Up with Hospital Births?

In many states, women who refuse unnecessary hospital procedures or who attempt home births are subject to state involvement, including threats from Child Protective Services. Things are even worse for women who want a vaginal birth after cesarean (VBAC), which many hospitals prohibit. But most American women, who don’t know that better alternatives exist or who don’t have access to those alternatives, continue to give birth in hospitals where their freedom to control their bodies is extremely limited.

This kind of government activity does not just affect birthing women and it is a primary driver of both cost and poor medical outcomes in other than obstetrics medical fields. Government intervention affects your access to at-home care, urgent care centers, decent and high quality primary care, and a range of other options that can lower costs and increase the quality of care. Until we are fully aware of how our choices are limited – even before we step into the hospital – by CON laws, licensing laws, reimbursement policies, and other regulations, our bodies will continue to be used and abused by the monopolists who control them.

Who are the Monopolists?

Governmemt is a monopoly. It claims powers unto itself and refuses anyone else entry. Medical schools are virtual monopolies or oligarchies. Most hospitals are monopolies or at the best enjoy limited competition and because they have all pursued Certificate of Needs procedures, they really are protected to a large degree from effective competition.

Anytime monopolies exist … even if it is government … red tape, inefficiencies and arbitrary rules will abound … and in the case of the medical profession – one of the most highly regulated sectors of the economy — this leads to lower quality service, higher costs, and a higher mortality rate.

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