By Asjylyn Loder
Friday, December 12, 2003
Even as demand for midwives increases in the United States, many are being forced out of business, leaving pregnant women with fewer options.
(WOMENSENEWS)--The birth of Miriam Singer's fourth child was tinged with a sense of loss for the mother, who knew that she was among the last few who would deliver a baby at the midwifery center at the University of Chicago Hospitals and Health System, where Singer had delivered all of her children.
The hospital stopped accepting new midwifery patients in early October after 18 years, and will soon close its doors despite an outpouringof community support from loyalists such as Singer.
The demand for midwifery care has more than tripled in the last decade, but rising insurance costs have made it difficult for midwives to stay in business. Midwives spend more time getting to know patients throughout their pregnancy and are less likely to intervene by inducing labor or performing Caesarean sections. For those reasons, many women favor midwifery care. But midwives earn substantially less than obstetricians and hospitals and independent midwives alike are finding it hard to shoulder skyrocketing malpractice premiums.
Midwives attended 305,606 births in the United States in 2001, or nearly 10 percent of vaginal births, a 100 percent increase from 1990, according to the National Vital Statistics Report by the Centers for Disease Control and Prevention. Studies have shown midwife deliveries to be as safe as physician-assisted deliveries. Of births attended by midwives, 97 percent take place in hospitals, where an obstetrician is on call to handle complications.
Singer, for example, suffered serious postpartum bleeding after the birth of her third child. Her midwife called in a physician to handle the bleeding, but stayed by Singer's side. Singer had a high risk of bleeding with the next delivery, but the midwife brought Singer safely through without complications while a physician remained on-call for emergencies.
Certified nurse midwives are typically registered nurses who have completed a Bachelor's degree, often in nursing, and earned advanced certification in the care of pregnant women.
There are no statistics on how many midwifery practices across the country have closed recently but several prominent midwifery services have been scaled back or closed since August.
On Sept. 29, Full Circle Women's Health, a nonprofit midwifery practice in Tallahassee, Fla., closed its doors after 20 years due to a rent hike and doubled malpractice insurance rates. In Des Moines, Iowa, a hospital that handles most midwife assisted births in the area cannot find enough physicians to meet the requirement that midwives work with two attending physicians and has let go four midwives as a result. In New Jersey, the last of three independent midwifery birthing centers closed in 2002.
New York saw an escalation of this trend this year. In August, the Brooklyn Birthing Center announced that its malpractice insurance had stopped covering midwives. Then, on Sept. 1, the prestigious Elizabeth Seton Birthing Center announced the closure of its Manhattan birthing rooms due to a 400 percent hike in malpractice insurance rates. In early October, New York Presbyterian Hospital initiated cutbacks in midwifery services at its Allen Pavilion branch.
Midwives displaced by the string of closings have found it hard to find a home elsewhere. In late November, four former Seton midwives quit St. Vincent's Hospital, complaining that hospital regulations--including a policy that advised recommending inducing labor six hours after membrane rupture--made it impossible for them to practice the methods of natural, noninterventionist childbirth that defines midwifery care.
As several high-profile midwifery services were forced to close their doors this year, women have rallied together to demand the greater continuity of care and attention that midwives provide.
In Austin, Texas, where hospital-based midwifery care was discontinued last year, midwives and former midwifery patients demonstrated in October to bring the midwives back, which may happen under new hospital managers. And in Chicago, midwifery patients marched on the University of Chicago Hospitals after it announced the closure of its midwifery practice.
Hospitals across the country are going through painful cost-cutting due to the rising costs of care associated with record-high insurance premiums. Even though midwives usually earn less than obstetricians, in lean economic times hospitals can be tempted to cut back on them and direct patients instead to obstetricians, because obstetricians are fundamental medical personnel. In addition, insurance companies often have lower reimbursement rates for midwives than obstetricians.
"The midwives are getting caught in the squeeze," said Deanne Williams, executive director of the Washington-Based American College of Nurse-Midwives.
Midwives earn on average $41,500 to $52,000 annually, topping out at $65,000, according to the University of Missouri Career Center--less than half of the $133,450 earned by obstetricians, according to the Bureau of Labor Statistics. The insurance plan endorsed by the American College of Nurse-Midwives costs from $7,000 to $32,000 per year, depending on experience, education and location. New York, and Florida are two of the priciest states to practice.
Obstetricians are also feeling the pinch with median premiums that increased 167 percent between 1982 and 1998, and rising steadily each year since. Last year, saw a 15 percent increase. Many doctors are choosing to close their practices.
The upshot is what many see as a triple negative for health-care participants.
"The loser is the physician who is overburdened, the woman who does not want to receive that kind of care and the midwife who is out of a job," said Williams.
Singer agreed. "Their availability is second to none. In terms of pre-natal care, I was able to call the midwives any time, the whole nine months," she said. Singer was able to see the same midwives through the births of all four of her children and the midwives stayed by her side throughout the duration of her labor, following her wishes to have a low-intervention delivery, qualities Singer doubts she could have found from a busy obstetrician.
"If I were to have delivered with an obstetrician, my delivery would mostly be attended by labor nurses that I didn't know and by residents," she said.
In scaling back its midwifery service, New York Presbyterian Hospital cited concerns over the safety of their patients, reclassifying "low risk" patients as "at risk," thus disqualifying them from midwifery care. Midwives counter that they have safely managed high-risk deliveries for years and that the maneuver is designed to force midwives out.
"We traditionally work with high risk populations and decrease the bad outcomes," argued Janet Brooks, who has been a midwife at Allen Pavilion for 14 years. "What they are saying is that they are changing to a medical model of care," she said. "A medical model of care means that there will be more interventions and the more interventions, the more money you can charge."
There is speculation that the change in policy is related to a $5.1 million Medicaid fraud settlement agreed to by the hospital earlier this year. The lawsuit alleged that doctors had fraudulently billed Medicaid for services performed by midwives.
Hospital spokesperson Bryan Dotson says patient safety, and not financial considerations, was the primary concern. He added that no midwives have been let go as a result of the new policy.
A late November study by American Baby magazine found that women attended by midwives were less likely to have a Caesarean and received less medication than women attended by an obstetrician. Statistics this year showed that 26 percent of babies in the United States are now delivered by Caesarean, in part because of guidelines by the American College of Obstetricians and Gynecologists that allow for elective Caesarean. The World Health Organization recommends a national Caesarean rate of 15 percent.
Asjylyn Loder is a freelance writer in New York.
American College of Nurse Midwives:
American College of Obstetricians and Gynecologists: