Maternity care -- who provides it, what it costs, how the baby gets out -- is much bigger than the so-called Mommy Wars. It's a question of the common good, and to get there, we need, as HuffPost blogger Randi Hutter Epstein recently noted, to go beyond the old "home vs. hospital" or "midwife vs. doctor" debates.
Recently, the Washington Post reported that America's largest private insurer, UnitedHealthcare, has promised to pay hospitals more if they can show that they are performing fewer elective (read: without medical cause) cesarean deliveries before 39 weeks. Other insurers -- including South Carolina's Medicaid program -- have decided to stop paying for early elective cesareans altogether.
The Department of Health and Human Services estimates that anywhere from 10 to 15% of babies born in the U.S. each year are delivered early without medical reason.
The reasons for these early deliveries are complex. Certainly, some women are pressured into early delivery by overworked obstetricians, who, as the most-frequently sued medical professionals, struggle to balance shrinking insurance reimbursements with ever-rising malpractice insurance premiums. But the pressure also comes from women themselves. The Washington Post quotes Alfred Khoury, director of maternal-fetal medicine at Inova Fairfax hospital: "After 37 weeks, patients really push for it because they are miserable and don't want to be pregnant anymore... Or they say, 'My mother is here' or 'I have to be in a wedding.' "
If such reasons sound silly or selfish, along the lines of "too posh to push" or "too pregnant to care," consider the cultural context: the rate of cesarean section in the U.S. is higher than it's ever been, and everyone from high-risk obstetric specialists and homebirth midwives agree that's a bad thing. (Even if they don't, the numbers do: despite spending more than any other country on maternity care, in 2011, the US ranked behind 49 other countries in terms of maternal mortality and morbidity.) Consider, also, our cultural tolerance for surgical procedures; in 2010, an industry research firm found that nearly half of Americans, regardless of income, approved of plastic surgery, and nearly a quarter found that they would consider it for themselves.
Furthermore, despite evidence to the contrary, there's a general perception that a cesarean delivery is safer -- a "surer thing" -- than a vaginal one, an attitude that almost certainly descends from misogynistic notions of the female body, and the uterus in particular, as "diseased." The history of maternity care in America is unlike that of other developed countries in that the time-honored profession of midwifery was all but annihilated thanks to explicitly racist and xenophobic smear campaigns in the early twentieth century against the "dirty," "poor" and "ignorant" black and immigrant midwives. (This is despite the fact that a 1912 Johns Hopkins study found that most American doctors at that time were "less competent than the midwives" they were replacing.)
Still, the most important factor, then and now, seems to be money. As Jennifer Margulis explains in her soon-to-be-released The Business of Baby: What Doctors Don't Tell You, What Corporations Try To Sell You, And How to Put Your Baby Before Their Bottom Line, there is a strong financial incentive to performing cesareans: cesareans, as major surgery, are often reimbursed at higher rates than vaginal deliveries. Besides that, they take a lot less time. "It doesn't matter [for reimbursement] if the delivery takes two hours or twenty four hours," writes Margulis. Vaginal deliveries can easily take upwards of twelve hours; cesareans can be finished in one hour from first incision to final stitch. The financial consideration of litigation, too, is considerable: as obstetricians famously say, "no one gets sued for doing a c-section."
Of course, the American College of Obstetrics and Gynecology takes a much higher-minded view. Jeanne Conry, president-elect of ACOG, told the Washington Post: "We oppose the legislative control of medicine." Similarly, an obstetrician in Texas insisted "outcomes are best when there is a doctor-led process, rather than a legislative or payment mandate." One could make a good case for the fact that financial incentives aren't in a patient's best interest, but then one would have to acknowledge that our current fee-for-service and maternity "crate rate" (where insurance pays one global fee, disincentivizing doctors to wait out pokey labors, for example) hasn't served women particularly well. Although death in childbirth is but a remote possibility for American women, it remains that, as Margulis points out, you're as much as four times more likely to die from giving birth via cesarean than vaginally, not to mention the fact that babies delivered via cesarean -- especially elective, early cesarean -- are much more likely to have breathing problems and require a stay in neonatal intensive care units.
This, after all, is why insurance companies have begun to refuse to pay for early elective cesareans: it cuts down on the fees they're likely to pay later. Another prudent move might be to cover doula services, which have been shown startlingly effective at reducing cesareans, or simply, as midwife Ina May Gaskin has suggested, to reimburse vaginal deliveries at higher rates than cesareans. Margulis is right: money incentivizes risky birth practices. But maybe there are ways to make financial motivations work for women.
Discussions of what is best in maternity care are often polarized as a choice between elective c-sections in high-tech hospitals and unattended home births in bathtubs, dismissed as a "battle zone in the Mommy Wars" or, worse, as a "status symbol" of hipness. But these lines are artificial, having been drawn not by mothers but by midwife-maligning men who believed that women's wombs were diseased and dangerous, and there are better models, models that don't pit one "side" against the other. And we don't even have to look to Sweden or the Netherlands to find them.
We can, for example, look to midwife Ruth Lubic, who used her MacArthur Genius award to found the Family Health and Birth Center in Washington, DC. Lubic attributes the Center's success -- it has outcomes twice as good as DC generally -- to their "high touch, low tech" support. Still, she says: "we can't function [without obstetricians] and really need to be a continuum. Families can't have the best care without this partnership."
It's not a question of who's "right," or which "side" you're on. It's about finding policies and practices that make it easier to do what's best for women, which is to say, what's best for everyone.
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