Scientific American - February 2019

6 Scientific American, February 2019

SCIENCE AGENDA

OPINION AND ANALYSIS FROM

SCIENTIFIC AMERICAN’S BOARD OF EDITORS

Illustration by Ramona Ring

Call the

Midwife...

If You Can

For better birth outcomes, the U.S.

should rethink maternity care

By the Editors

Despite the astronomical sums that the U.S. spends on mater-
nity care, mortality rates for women and infants are significantly
higher in America than in other wealthy countries. And be cause
of a shortage of hospitals and ob-gyns, especially in rural areas,
many women struggle to access proper care during pregnancy.
Moreover, the rate of cesarean sections is exceedingly high at
32  percent—the World Health Organization considers the ideal
rate to be around 10  percent—and 13  percent of women report
feeling pressured by their providers to have the procedure.
Widespread adoption of midwife-directed care could allevi-
ate all these problems. In many other developed countries, such
as the U.K., France and Australia, midwifery is at least as com-
mon as care by obstetricians. In the U.S., certified midwives and
nurse-midwives must hold a graduate degree from an institution
accredited by the American College of Nurse-Midwives, and cer-
tified professional midwives must undergo at least two years of
intensive training. This is designed to make midwives experts in
normal physiological pregnancy and birth. Thus, for women with
low-risk pregnancies who wish to deliver vaginally, it often makes
sense to employ a midwife rather than a more costly surgeon. Yet
only about 8  percent of U.S. births are attended by midwives.
The roots of America’s aversion to midwifery go back to the
late 1800s, when the advent of germ theory and anesthesia re -
duced much of the danger and discomfort associated with child-
birth. The benefits of these technologies brought doctors to the
forefront of maternity care and pushed midwives aside. Obste-
tricians helped to bar midwives from practicing in hospitals,
which were now considered the safest birth settings. By the ear-
ly 1960s midwifery was virtually obsolete.
It has made a comeback since then, with practitioners just as
well trained as doctors to supervise uncomplicated deliveries.
Studies show that midwife-attended births are as safe as physi-
cian-attended ones, and they are associated with lower rates of
C-sections and other interventions that can be costly, risky and
disruptive to the labor process. But midwifery still remains on
the margins of maternity care in the  U.S.
To bring it back into the mainstream, midwives must be fully
integrated into the medical system. Some states currently refuse
to recognize them as legitimate practitioners, and some severe-
ly limit what midwives are allowed to do, despite evidence that
states with the most restrictive policies also have some of the

highest rates of adverse birth outcomes, such as deaths of new-

borns. If midwives were allowed to work alongside other provid-

ers, patients would get the care advantages, and if difficulties

arose, a woman whose home birth suddenly became complicat-

ed could be seamlessly transferred to a hospital.

Even when state laws are favorable, women who wish to work

with midwives often face financial obstacles. Medicaid will cover

all midwifery services, according to the Affordable Care Act, but

the requirement does not extend to private insurers, many of

whom lack in-network midwives or refuse to cover midwifery care

at all. Half of planned nonhospital births are currently paid for by

patients themselves, compared with just 3.4 percent of hospital

births. Thus, a less expensive birth at home may paradoxically be

out of reach for women who cannot afford to pay out of pocket.

U.S. hospitals charge more than $13,000, on average, for an un -

complicated vaginal birth, whereas a similar midwife-attended

birth outside of the hospital reduces that figure by at least half.

Insurers would save money by embracing midwife-attended, non-

hospital birth as a safe and inexpensive alternative.

A national shortage of birth centers further limits women’s

choices. These homelike settings are designed to support natural-

ly laboring women with amenities such as warm baths and spa-

cious beds and are consistently rated highly in surveys of patient

satisfaction. Yet there are only around 350 existing freestanding

birth centers in the entire nation, and nine states lack regulations

for licensing such facilities. More government support for birth

centers would help midwives meet a growing demand, which has

already fueled an increase of 82  percent in centers since  2010.

Policy makers, providers and insurers all have good reasons

to encourage a shift toward midwifery. The result will be more

choices and better outcomes for mothers and  babies.

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