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Homebirth Midwives and the Hospital Goliath: Evidence Builds for Disruptive Innovation

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"Midwives have a central focus in our strategic plan. We are hoping Washington State can double out-of-facility births in the next two or three years."

The speaker was Jeff Thompson, M.D., MPH, chief medical officer of the state of Washington's Medicaid program. He spoke in a taped interview for Symposium 2012 -- Certified Professional Midwives and Midwifery Educators: Contributing to a New Era in Maternity Care. The gathering took place at Warrenton, Va.'s Airlie Center on March 18, 2012.

Thompson, a member of the National Advisory Council for Healthcare Research and Quality, works in the state with the most evidence-based exploration of the value and risks associated with direct-entry, licensed, non-nurse, midwives. His state's heightened interest began with a state requirement in 1996 that health plans cover midwives. Washington, like 11 other states, presently also covers midwives via Medicaid.

If the certified professional midwives (CPMs) get their way in Congress, CPM services will be reimbursed by Medicaid in all 26 states where CPMs are licensed. Passage would significantly expand access to low-income women across the country. The Access to Certified Professional Midwives Act was introduced in the U.S. House of Representatives in 2011 by Congresswoman Chellie Pingree (D-ME). Passage would energize a slight bump in home births captured in recent data from the Centers for Disease Control.

In addition, the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act, introduced by Congresswoman Lucille Roybal-Allard, includes CPMs throughout a range of provisions that would effectively foster a renaissance in maternity care in the U.S.

Thompson believes the new states will like the changes these laws would bring: "Midwives have a phenomenal record. C-section rates are lower in those who use midwives." He said that with low-risk mothers choosing home birth, "We know that the rate is 8 percent, while it's around 20 percent in an obstetrics facility." Overall C-section rate ranges from 15 percent from 40 percent in Washington state facilities, according to Thompson. The average rate of C-section is over 30 percent nationwide.

Outcomes on satisfaction with home birth midwives is high, says Thompson: "One issue we can learn from midwives is the customer service in midwifery care."

Thompson completes the midwives' "Triple Aim" evidence trifecta with reference to cost. In his state, Medicaid payments to licensed midwives for uncomplicated vaginal birth runs $2,500. Payment for birth center births is $5,000 and doubles again to $10,000 for those performed inside of hospitals. The cost doesn't touch additional savings from reducing the rate of often over-used medical interventions such as epidurals and inductions of labor.

He closed with reference to the social costs of the current system: "Of the $600 million Medicaid spends annually on hospital costs in his state, 30 percent reflects delivery costs. The unintended consequence of not pursuing something like [expanding the home birth option] is that we don't have enough resources to spend in other ways."

The Airlie Center is famous for convening dialogues on peace and justice. A presentation the next morning from obstetrician Tim Fisher, M.D., FACOG, laid out some of the economic power pitted against midwives and rational policy in the battle for control of birth.

A participant asked Fisher whether the new financial incentive in the emerging accountable care organizations (ACOs) might make hospitals more aligned with midwives. If they share in ACO savings, might they proactively refer for lower cost home birth?

Fisher heads up a Dartmouth-Hitchcock clinic in New Hampshire and sits on the Northern New England Perinatal Quality Improvement Network. He ticked off data of another sort. The number one surgery performed in hospitals is C-section. The number one diagnostic-related group (DRG) in hospitals nationally is birth. The number two surgery in hospitals is hysterectomy, often associated with birth. Fisher summed up the importance of current practice to our tertiary care-focused delivery structures: "Birth keeps the lights on in hospitals."

Hopes of an emerging alignment are not helped by the 2010 position of the American College of Obstetricians and Gynecologists (ACOG), of which Fisher is a fellow. ACOG reaffirmed its position that the college "does not support individuals who advocate for, or who provide home birth."

Fisher presented the midwives with a strategic recommendation: "Your best move is to go straight to the people who write the checks -- go straight to Congress."

The licensed midwives are in fact three years into a campaign to do just that. The CPMs and the Midwives and Mothers in Action (MAMA) campaign achieved a first victory in 2010. U.S. Senator Maria Cantwell, also from Washington state, included licensed midwives as covered providers in birth centers in Section 2301 of the Affordable Care Act. This put licensed midwives in federal health care law. The focus now is on Pingree's Access to Certified Professional Midwives Act.

The MAMA Campaign has raised a remarkable $350,000 to support their lobbying effort since 2010, despite counting just 2,000 licensed CPMs nationwide. A former staffer to the U.S. Senate Finance Committee has been retained to support a lobby team led by Mary Lawlor, CPM, LM, MA. The bill has 10 sponsors, all Democrats, including medical doctor Jim McDermott, M.D. (D-WA). Participation from the Republican side has been stifled by antagonism to anything linked to government-run health care.

The midwives assembled at the Airlie Center know that the evidence that pushed the state of Washington to promote home birth may not be sufficient to get the other Washington to turn its back on the likes of ACOG. A major new profession-wide data collection project by the North American Registry of Midwives, the profession's certification agency, was announced to forceful applause.

Resistance is not surprising. Home birth represents disruptive innovation of the first order for the nation's hospitals and obstetricians. Moving low-risk birth to our homes or birth centers is a slingshot to the temple of tertiary care-intensive medicine. For a system that leaders of the Institute of Medicine have characterized as half waste and much of that harmful, the home birth model appears a direct hit.

Consider the potentially long-term positive consequences if mothers and families learn that most can have their babies at home, without all that expensive intervention. Might human beings with such an experience of self-care and empowerment in the act of giving birth be more disposed toward achieving self-efficacy in other parts of their care? Might what Washington state is promoting prove an exceptionally powerful force in fundamentally transforming health care?

Lawlor, the MAMA campaign's point person on the Hill, believes the argument is gaining ground in Congress. She says members and their staffs are beginning to be comfortable talking about the "midwifery model of care." No wonder. The triple aim of access, quality and cost are all tipped in the favor on this most ancient of innovations.

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