Why Midwives Are Fast Becoming More Popular Than OBGYNs

Midwives often come up in conversations of home births and even Goop moms, often deemed problematic. But theyre fast becoming an effective primary and reproductive health care option as womens access to healthcare (especially if theyre low-income) is rolled back.

The rising profile and respectability of midwives has also sparked debate over whether they can be part of major public health solutions in the United States. But certified nurse-midwives and certified midwives independent practice within the healthcare system is still limited, varying by state.

Independent has become a dirty word, Lisa Kane Low, president of the American College of Nurse Midwives and associate professor at the University of Michigans School of Nursing, said. Powerful organizations such as the American Medical Association, according to Kane Low, take the word independent to mean not within any kind of health care structure that supports interaction and collaboration.

A first-of-its-kind study published last month in the journal PLOS One found states where midwives are more integrated into the system also reported better maternal care outcomes.

Advocates for untethering midwives from physicians say the stigma around independence hurts women, especially as physicians organizations like the American College of Obstetricians and Gynecologists (ACOG) have supported their full scope, autonomous practice, as qualified, accountable providers who work collaboratively with ob-gyns in an integrated maternity care system that promotes seamless access to appropriate care.

When you are in the trenches together, we support each other. It doesn't feel like there's a turf war. It feels like we are all working together.
Holly Smith, California Nurse Midwives Association

If a nurse midwife is trained appropriately to provide well woman services or primary care services, we support that, Dr. Hal Lawrence, ACOG's CEO and EVP, told The Daily Beast. A model of team-based care, which ACOG supports, does not mean a doctor must always supervise a midwife.

But doctors and nurses dont make the legal cut, and the power struggle for midwives has run deep. A century ago, midwives were subordinated as physician specialization grew. Dr. Joseph DeLee, considered the founder of modern obstetrics, declared childbirth a pathologic process, introduced forceps, sedatives and episiotomies and denounced midwives as a relic of barbarism.

The United States attitude toward midwives differs from other developed countries, including Canada, Australia and England, where midwives lead the obstetric system with stronger birth outcomes.

Currently, full supervision requirements in five statesCalifornia, Nebraska, North Carolina, South Carolina, and Floridaand partial supervision requirements in dozens of others limit the services midwives can provide, and where they can provide them. This restriction can especially hurt low-income and rural communities, according to Kane Low. In 27 states and D.C., certified nurse-midwives can legally practice without physician supervision.

Something that always has been a core part of midwifery is going where we are needed, Sheri Mateo, secretary of the California Nurse-Midwives Association, told The Daily Beast. More midwives would do that if we werent tethered to physicians. By allowing certified nurse-midwives or certified midwives to practice independently in more areas of the country, ACNM argues, women would have more access to primary and maternal health care.

What people dont realize is that there are different categories of midwives, who work mostly in hospitals and deliver less than 9 percent of births in the United States. In the U.S., becoming a certified-nurse midwife requires a person to be an advanced-practice nurse with a masters degree to meet the standards set by the tight-knit International Confederation of Midwives. A certified midwife has or receives a receive less training background in a health-related field (not nursing), graduates from an accredited midwifery education program, and must pass the same exams as her nurse peers.

It boils down to who is in control, said Kane Low, whos practiced as a CNM for 30 years. And unfortunately in some states, partially through the lens of the AMA, the idea that you would be independent is turned into somehow youre going to go rogue.

A New Public Health Crisis

A doctor shortage is looming, and the U.S. has the highest rate of maternal mortality in the developed world, especially for black women. Meanwhile, employment of nurse-midwives increased by about 23 percent between 2014 and 2016.

More than half of rural U.S. counties lack hospital obstetric services. The Wall Street Journal reported last year that women in rural areas are 64 percent more likely to die in childbirth than in urban areas. God damnit! Rural areas should only have higher concentrations of Waffle Houses! the late-night Samantha Bee joked in a skit on the maternal health care crisis in January. Maternity-care deserts also rely heavily on Medicaid, a program Republicans have long been promising to gut.

Midwives work with healthy, child-free women to provide birth control, abortions, or routine exams. About 50 percent of CNMs identify reproductive care and 33 percent identify primary care as regular responsibilities, according to the ACNM.

Critics of midwives independent practice, including the AMA, think we are trying to remove obstetrics, Holly Smith, health policy co-chair of California Nurse-Midwives Association, said.

Obstetrics include procedures like fetal screening and Caesarean sections. "We feel that we made a lot of progress in making connections with our physician counterparts, Smith added. We are attempting to change a law and a culture of care that has been around for decades and permeates the way we think about the best way to care for women during pregnancy and birth.

At the center of the debate over what to make of midwives is the political battle over womens health, on which both the government and scientific community have historically fallen short.

A 2014 editorial in the New York Times referenced British research that found midwives delivered safer uncomplicated pregnancies than doctors, and alluded to the longstanding turf war between obstetricians and midwives.

Midwives in general are huge patient advocates, and throughout the health care system, they bump into areas where women are not getting their needs met, Julia Phillippi, a CNM and assistant professor at Vanderbilt University, told The Daily Beast. Phillippi authored a 2015 paper about this very topic in the Journal of Midwifery and Womens Health.

We cost less to pay, we have good outcomes for low-risk women, Phillippi added. If you are a health system trying to care for vulnerable women who don't have health insurance, nurse midwives are often a cost-effective option.

Many women are simply unaware that they can seek primary care from a midwife.

I worked for years clinically as a midwife. We would say we work full scope… We had to stay in our lane and do OBGYN care, Mateo said. It has varied for midwives across the board, and many times we are not being allowed to function to the top of our education, to the top of our license.

Some midwives who work under doctors on a regular basis say its harmonious and not necessarily reflective of the higher-level politics. But the position of ACNM is that such restrictions create ambiguity around which provider is accountable and how power is distributed on a teamthough that might change in the future.

When you are in the trenches together, we support each other, Smith, the CNM in California, said. It doesn't feel like there's a turf war. It feels like we are all working together.

Read more: https://www.thedailybeast.com/why-midwives-are-fast-becoming-more-popular-than-obgyns

Why does it cost $32,093 just to give birth in America?

The US is the most expensive nation in the world in which to have a baby and it may factor into thousands of bankruptcies each year

Why does it cost $32,093 just to give birth in America?

The US is the most expensive nation in the world in which to have a baby and it may factor into thousands of bankruptcies each year

Read more: https://www.theguardian.com/us-news/2018/jan/16/why-does-it-cost-32093-just-to-give-birth-in-america

‘A third of people get major surgery to be born’: why are C-sections routine in the US?

Caesareans have transformed from life-saving intervention into risky procedure performed for one in three births and often geography is the deciding factor

Carmen Walker didnt realize how bad things had gotten until she heard her doctors voice from across the operating room: Im going to try to save her uterus.

Walker had delivered her first child by caesarean section, so when she became pregnant a second time, doctors didnt think twice before scheduling another. And then another and another. Now, giving birth to her sixth child, she was experiencing the consequences: placenta accreta, a condition which is linked to multiple C-sections and can result in fatal bleeding.

Caesarean sections have saved the lives of millions of infants who might have otherwise been killed or permanently injured during difficult births. But in the US, the rate of caesareans has increased so much over the decades that the surgery has been transformed from a life-saving intervention into a procedure performed as a matter of course during one in three US births.

In 2015, the latest year for which the Centers for Disease Control has data, the share of births by C-section was 32%. The World Health Organization has suggested that the rate should not be higher than 10% – 15%, while other experts have suggested it should not be higher than 19%. The last time the USs rate was that low was during the 1970s.

Carmen
Carmen Walker and her sixth child, Olivia. Photograph: Carmen Walker

We are quite worried when the C-section rate goes above 30%, as it is in the United States, said Dr Flavia Bustreo, the assistant director general for family, womens and childrens health at the World Health Organization. It becomes routine but it is still a major surgery. That carries a long-term effect on maternal health.

A C-section rate of 10% to 15% is natural, she said. Above 15%, you dont have additional benefits, and you have the risks, and you have the unnecessary health costs.

A third of people get major surgery to be born, said Dr Neel Shah, a practicing OB-GYN and an assistant professor at the Harvard School of Medicine who works on ways to reduce avoidable C-sections. Many of the mothers in that equation were having a low-risk birth, he added that is, there were few or no medical indications that a C-section was necessary.

That is hundreds of thousands of women every year who get surgery they never need in the first place. Thats crazy. We can do much better than that.

The caesarean rate in the US has shot up by roughly 50% since the 1990s

The associated risks are serious. For the mother, they carry the potential for deadly bleeding, a lengthy recovery, organ damage and permanent injury. Compared with women having a vaginal birth, those having a C-section for the first time have 3.1 times greater risk of blood transfusions, a 5.7 times greater risk of an unplanned hysterectomy and a six times greater risk of being admitted into intensive care.

The rate of C-sections is now well beyond what is medically justifiable to save the lives of infants, experts say.

As C-section rates in the US have gone up, there has been no accompanying rise in infant survival rates. In the case of low-risk mothers, theres not a lot of evidence of improved outcomes, said Eugene Declercq, a professor at the Boston University School of Health who studies caesareans. Its just not there.

Women having a first-time caesarean in the US face a greater risk of dangerous pregnancy complications than women giving birth vaginally

In fact, some experts believe this rise in caesareans is one of the many intertwining factors contributing to crisis rates of maternal mortality, or death, and morbidity defined as significant injury related to a pregnancy.

Its certainly one of the downstream consequences of performing avoidable C-sections, said Jill Arnold, who runs a website that tracks individual hospitals C-section rates, and works as a consultant to Consumer Reports. Its connected to seeing more women bleed out, or have near misses.

Placenta accreta, for example, the condition that nearly killed Walker, is roughly 600 times more common today than it was in the 1950s, an increase scientists have linked to the rise in C-sections.

A 2007 analysis of more than two million birth outcomes in Canada found that women with low-risk pregnancies were three times more likely to die or be seriously injured if they had a C-section rather than a vaginal delivery. The findings helped move the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to put out a joint call in 2014 for reducing avoidable C-sections.

For most pregnancies, which are low-risk, caesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery, the groups said.

In the US, the rate of maternal deaths per 100,000 live births is 26.4, and it has been rising since 2000. Just about every other western country has seen a decline in maternal death rates since 2000, and the next closest western country, the UK, has a mortality rate of 9.2 per 100,000 live births.

It is very, very clear to me the connection between the number of C-sections and mortality and morbidity, said Dr Shah.

Whats not so clear is whether c-sections are whats causing maternal mortality rates in the US to rise. Declercq, who notes he is no fan of unnecessary C-sections, says the bigger drivers of maternal mortality probably include factors like the opioid crisis and the fact that many new mothers are dropped fromMedicaid, the government-run health program, shortly after they give birth.

Just addressing the C-section rate alone wont reduce the maternal mortality rate. Other developed countries have C-section rates that are as high as the United States. A 2012 international comparison found that the C-section rate was 21.8% in Norway and 24.4% in the UK but 31.7% in Germany and 26.2% in Canada.

But those countries also have medical teams that are better at recognizing and treating life-threatening pregnancy complications, investigations have found, and experts note they do not face factors like poor access to maternity care.

Why is the C-section rate rising?

The factors that drove up the rates of C-sections are numerous and difficult to untangle. Women who are older, heavier or have certain health conditions can be more likely to need a C-section to deliver a healthy baby.

But changes in the US population dont completely explain the increase seen since the 1970s. One factor is that doctors recommend C-sections when they believe the fetus is showing signs of distress, but many hospitals have a culture or use technologies that send a physicians better-safe-than-sorry instincts into overdrive.

Fetal heart monitoring strips, which produce a steady stream of information about a fetuss vital signs, are a prime example, said Declercq, because they furnish physicians with a torrent of information including, inevitably, false positives to scrutinize for signs of trouble. The rise in C-sections since the early 1970s closely tracks the introduction and widespread adoption of fetal heart monitors.

Then theres the fact that C-sections dont look like a public health disaster to those up close and personal with them.

I didnt realize this was a problem until you zoom way out, said Dr Shah. Theyre so common they look fine. And people are usually fine. They had their babies and they love their babies. Even people who had a stressful birth experience tend to look back fondly.

Many doctors and hospitals are in the dark about the rate at which they perform C-sections for low-risk births, because none of the government agencies or accreditors who oversee hospitals require the figures to be public. Arnold said she once heard of a hospital CEO crying the first time she learned her hospitals figures.

Pilot programs have found that, just as in Arkansas, the simple act of disclosing the numbers can cause hospitals to reduce their rates.

Many hospitals have a long way to go. Healthy People 2020, a federal initiative to improve US health outcomes and Leapfrog, a nonprofit that lobbies hospitals to release various health metrics as a way to improve overall care, deems a hospital to meet acceptable standards if C-sections account for no more than 23.9% of births.

In 2016, 55% of hospitals who voluntarily reported data to Leapfrog had a C-section rate that was higher than 23.9%, or 730 hospitals out of more than 1,300. At 223, or nearly 17%, more than one in three births takes place via C-section.

Honestly, it should be lower, Arnold said, referring to the 23.9% threshold. Even hospitals with high-risk patients, every hospital should be able to hit that number.

C-section rates by hospital

Geographical disparities

And yet, in the US, a womans odds of undergoing this risky operation are completely untethered from whether or not her circumstances require it.

A womans greatest risk factor for having a C-section is what hospital she chooses. Looking at a map, its normal for one hospital to have double the caesarean rate of a neighboring hospital located less than a mile away and serving the same community. Other times, geography equals destiny. The south in particular contains whole communities served only by hospitals where the caesarean rate is 33% or greater.

Walkers story illustrates the point. Her first caesarean was necessary, she says. She was in labor for 36 hours, but she never dilated enough to deliver vaginally.

But by the time she was pregnant with her second child, she lived in Mississippi, a state that had a C-section rate of 36.8% in 2014 and where scarcely any OB-GYNs are willing to attempt a vaginal delivery after a woman has already had a C-section. Her lack of options, she says, locked her into a succession of increasingly risky operations.

Walker wound up lucky. Although she spent three days on high-risk watch in the hospital and would still be undergoing a painful recovery months later, her doctor stopped the hemorrhage. The blood loss meant she remembers little about the initial aftermath, but she remembers being unable to stand up under her own power.

Her complications could have been far more severe. Placenta accreta patients account for 38% of caesarean-related hysterectomies, and up to 7% of women with placenta accreta die.

Read more: https://www.theguardian.com/lifeandstyle/2017/oct/04/one-in-three-us-births-happen-by-c-section-caesarean-births

Photo Of Baby Lying Next To Moms C-Section Scar Shows Us What Mothers Go Through

Pregnancy and birth happen as they do, yet many women are openly judged if a “not natural” option is chosen. Recently, photographer Helen Aller, from Guernsey, UK, took this intimate photo of a mother and her three-day-old baby boy next to her caesarean incision. The woman, who did not want to be identified, had decided on a vaginal birth, but was forced to have an emergency caesarean due to complications. She wanted a picture taken of the operation that saved her and her baby.

“I photographed this mama’s pregnancy a while back and she was telling me how terrified she was of having a c-section,” wrote Aller on Facebook. “Well last week she went into labor but had to have an emergency c-section after complications. She asked me to come over this morning and shoot this particular image as her worst nightmare proved to be what saved her and her child’s lives.”

“[She] wanted something to show that her biggest fear was what in the end saved both of them. I think she will see that scar and appreciate the life they were given”