Women’s Rights vs States’ Rights: The Ongoing Battle and How it Affects Birth Settings

Image by J. Costea Photography http://www.jcosteaphotography.com/

We are facing a national women’s crisis, and nobody’s willing to do anything about it. Is it because the operative word here is “women”? Because that’s what it feels like. In the US, the vast majority of women don’t have a choice as to where they are going to give birth because of the widespread belief among medical professionals and policy-makers in the US that only hospital births are safe. In reality, traditional, out-of-hospital settings, such as freestanding birth centers and home births, have been proven safer and cheaper for low-risk, healthy pregnant women. Countries with socialized medicine know this and are actively recommending it because healthy women having healthy babies in hospitals are a strain on their system, as they know it leads them to more unnecessary, costly interventions.

This past December, the UK’s National Institute for Health and Care Excellence (NICE) published new guidelines for caring for healthy women with uncomplicated pregnancies. They now officially recommend that healthcare providers inform low-risk, pregnant mothers “that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth”, and to advise them that “giv[ing] birth at home or in a midwifery‑led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit”.

Though the rate of out-of-hospital births in the UK varies, the integral difference there is that women can actually choose to have a home birth with the support of their hospital. For example, Northampton General Hospital in the UK serves a population of about 360,000 people. In December 2013, they opened the Barratt Birth Center, their own midwife-led center. They’ve had their own home birth team since 2010, made up of eleven midwives, who take care of all prenatal and postpartum appointments in your home (as well as the birth, of course). The first words on their website are, “All women should be offered choice when deciding where to birth their babies.”

The Safety
Many Americans will say, “That’s all well and good, but we need OUR OWN studies.” We have them… They exist! The US has had three major birth center studies in the last 26 years, all of which have confirmed, and still confirm, that birth centers are a safe and viable option for low-risk mothers. In January of 2013, Outcomes of Care in Birth Centers: Demonstration of a Durable Model, AKA “The National Birth Center Study II” was published in the Journal of Midwifery and Women’s Health and nobody heard about it. This is the most recent study and concludes two very important things:

1) “Midwife-led birth centers are a strong model for decreasing the high rate of cesarean birth in the U. S., while maintaining the highest safety standards. ” and,
2) “Increased use of birth centers would lower direct and indirect costs to the American health care system.”

The Money
Currently, the average cost of having a vaginal delivery with no complications in a hospital in the US is roughly $18,000. The real cost is much higher, but much of this cost is covered by medical insurance, which drives up the cost of insurance for all women of childbearing age and puts undue financial strain on new parents. This doesn’t include the 48% of births that are covered by Medicaid, which puts financial strain on the whole country. It’s been reported over and over again that the US is the most expensive country in the world in which to give birth. Compared to the average cost of vaginal birth center delivery, which is $2,200, this is obscene.

The Birth Center II study estimated that the 15,574 women who took part in the study saved a combined total of $30 million in medical expenses. That’s an average savings of $1,930 per person.  Flip that around and that’s $30 million that hospitals didn’t make. Imagine if 85% (the CDC estimated percentage of low-risk pregnancies) of the 2,642,892 vaginal births that took place in the US in 2013 were all out-of-hospital births, instead; that’s $4.3 billion annually that would be taken out of hospitals and kept in the pockets of parents. It’s undeniable that vaginal births are simply less costly. The 2011 average Medicare/Medicaid reimbursements for an uncomplicated, vaginal birth was over twice as much for a hospital birth than for a birth center birth. The American Association of Birth Centers (AABC), the first reporters of the publication, explains that, “Even if birth center reimbursements were adjusted to make payments fairer and more in line with hospital births, a decreased use of interventions would still translate into a significant cost-savings for insurance companies.” Another factor to consider is the US’s 27% C-Section rate for low-risk women, compared to the women in the Birth Center II study, who had a 6% C-Section rate. Using those rates, if all of those 15,574 women had chosen to give birth in a hospital, that would have amounted to 3,000 extra (completely unnecessary) C-Sections.

The Standards of Care & Oversight
Somehow, state officials feel they have the requisite knowledge to dictate what’s medically safe and what’s not. They do not. Just look to Idaho, where a state representative recently had to be given a lesson on female anatomy when he suggested women have remote gynecological exams by swallowing a microscopic camera. These are the people entrusted to regulate vaginae (yes, that’s the plural). Lest you think this is a push to rebrand your local theater as a birth center, there are legitimate standards and practices that birth centers across the nation can and should be held to. The Federal Trade Commission (FTC) endorses both the “National Standards for Birth Centers” and the “Best Practice Guidelines: Transfer from Planned Home Birth to Hospital,” but it’s up to each state to implement those standards and practices. There is national accreditation through the Commission for the Accreditation of Birth Centers (CABC) that provides crucial leadership such as policy and procedure oversight, accountability, a standard of care, and site visits every 3 years. This accreditation is supported by the American Congress of Obstetricians and Gynecologists (ACOG) who, in conjunction with the Society for Maternal-Fetal Medicine, just released an Obstetric Care Consensus, including Levels of Maternal Care and listing licensed midwife-operated Birth Centers as their own, qualified level.

Let’s focus in on the care providers themselves, for a moment. We’re not talking about letting any Tom, Dick, and Harry say they’re qualified to deliver your baby anywhere, anytime. No, that would be irresponsible. In the US, there are four main types of midwifery certifications: Certified Midwives (CMs) and Certified Nurse-Midwives (CNMs) are accredited by the American College of Nurse Midwives (ACNM); Certified Professional Midwives (CPMs) are accredited by the North American Registry of Midwives (NARM); and Direct-Entry Midwives (DEMs), who are skilled, licensed and trained, but currently have no national accreditation board.

Now, if your mother delivered all of her children at home and you decide you want her to oversee your home birth, that’s fine too. That should be your prerogative. Obviously, if she’s marketing herself as a professional baby-catcher and charging people for her services, that’s another story. Women should be able to choose who attends their birth but should also have a guaranteed standard of care when they pay for professional medical services. This is what the adoption of a national system of accreditation and scope of practice for all four classes of midwives would help to ensure.

State-by-State
When you bring it all down to the state level, you can clearly see where all of these national efforts fall apart. CNMs are legally allowed to practice in all 50 states plus DC but with varying degrees of supervision by a physician. When physician supervision is required, their scope of practice is limited by the physician’s personal level of comfort (i.e. you cannot perform a homebirth if your supervising physician isn’t pro-homebirth because he doesn’t want that “liability”). There are currently only 28 states in which CPMs are legally allowed to practice; everywhere else, they are forced to work outside of the law to provide quality birth center and home birth care. Even in the states where they are allowed to practice, state legislature and the respective Health Departments can dictate what midwives aren’t allowed to do, and what they must do. These arbitrary and often sorely outdated regulations hinder the ability of the midwife to properly care for a pregnant or laboring woman. The “unlawfulness” of what these women are doing is what needs to be stressed, here. In the states where they are not legally authorized to attend home births, a licensed, certified, qualified midwife can not only have her license revoked, but can be thrown in jail for helping a mother deliver a perfectly healthy baby with no complications.

Head on down to the South (unless you want to have a baby) to see how backwards things have gotten. We’re currently in the process of helping to change legislation on a tri-state level: North Carolina, South Carolina, and Georgia. NC is one of the “we will throw you in jail” states. As a pregnant mother, you are welcome to birth at home, but for the most part, you must do it without one of these licensed, certified, experienced professionals. Nobody other than CNMs are allowed to work in a birth center setting. There are a handful of CNMs in the state who are doing home births under physician supervision, but they are few and far between. CPMs who attend a homebirth can and will be charged with a Class 3 Misdemeanor if the authorities are notified. As a pregnant mother you are, however, allowed to hop over the border into SC, and deliver your baby at a friend’s house. There, CPMs are currently allowed to attend homebirths, but the legislation is being constantly reinterpreted (though not rewritten) by the Department of Health and Environmental Control (DHEC), and they have been leaning on birthing centers all over the state for decades, finding ways to close their doors. In GA, the Department of Human Resources dictates that “No person shall practice midwifery without first receiving from the Department of Human Resources a certificate of authority”. This would be great, except that, according to midwives who have gone through the proper process, Georgia’s Department of Human Resources simply won’t provide certification for anyone. Period.

The Bottom Line: My Uterus, My Health, My Choice
So, we’ve established that this issue is not about safety, it’s not about questionable standards of care, and it’s DEFINITELY not about what’s best for mother and baby. States are actively opposing women’s rights, masking it with the “only we know what’s best for you” argument, when that’s blatantly a lie. What women need now, as in right this very minute, is for states to recognize National Accreditation for birth centers and midwives and then leave us to it. Birth is natural, birth is safe, and it’s high time we take our uteri and vaginae out of the hands of state politicians, whose policies contradict evidence of the safety of midwife-assisted births at home and in freestanding birth centers.