Midwives Deliver Healthier Babies with Reduced Costs
Horvitz, Leslie Alan, Insight on the News
A recent study indicates that mortality rates and birth defects can be lowered -- at $1,500 less than the cost of a hospital stay -- if more expectant mothers choose midwives to deliver their babies.
Although pregnancy is the most common reason why women are hospitalized, doctors, nurses and health experts disagree on the best way to deliver infants. The debate is far from academic: The United States has a higher infant-mortality rate than 23 other industrialized countries (as of 1991, the most recent year for which data is available), despite that it has reduced the rate to 8.5 per 1,000 live births during the last three decades.
The leading causes of infant mortality and morbidity are birth defects, low birth weight and prematurity. But a new study of 1,300 low-risk pregnant women conducted by researchers at the University of Washington offers compelling evidence that mortality rates and birth defects can be lowered -- with considerable savings in cost as well -- if more women choose certified nurse-midwives, or CNMs, to deliver their babies.
Earlier research has shown that midwives have had better results than either obstetricians or family physicians, but the Washington study offers the first comparative profile of all three providers. CNMs are less likely to use continuous fetal monitoring, induce or augment labor or perform interventions such as epidurals (anesthetizing the patient from the waist down) or episiotomies (making an incision in the vaginal area to prevent tissue tears). The study also validated previous findings that midwives deliver only 1 to 3 percent of births at low weight (less than 2,500 grams), compared with 7 percent by obstetricians and 8 percent by family physicians.
Moreover, patients under the care of CNMs had substantially lower cesarean-section, or C-section, rates -- 8.8 percent, compared to 13.6 percent for obstetricians and 15.1 percent for family physicians. Altogether, CNMs used 12.2 percent fewer resources than their physician colleagues who tended to be older -- and mostly male.
"Taken in its totality, this body of knowledge suggests that the approach to low-risk obstetrics as used in the real world by midwives has significant advantages for patients," wrote Roger A. Rosenblatt, principal investigator for the study, which was funded by the Agency for Health Care Policy and Research. Or more simply put: In contrast to obstetric care, nurse midwifery is "high touch and low tech."
While midwives are common elsewhere in the world, they attended only 218,466 of all births in the United States, or 5.5 percent, in 1994. But the trend is changing, with midwives caring for roughly 15 percent more Americans each year. Six thousand CNMs practice in the United States and another 400 are certified every year.
"Some people think a midwife is a midwife is a midwife," says Deanne Williams, interim administrative director of the American College of Nurse-Midwives, or ACNM, in Washington. But this isn't the case, she says. CNMs are licensed health-care practitioners who receive two to three years of specialized training.
The proportion of midwife-attended births varies enormously between states, however, with 19 percent recorded in New Mexico (the highest) and 1 percent in Kansas, Louisiana and Nebraska. (New Mexico has a large population of American Indian mothers who prefer traditional ways of delivering their babies.) Mothers who use midwives tend to be older, better educated and married -- and have lower risk for obstetric complications.
One indication of the growing popularity of midwives: The number of training programs, now around 50, has trebled during the last four years. The ACNM points out that although licenses and certification are necessary to practice virtually every profession including cosmetology, states have developed no uniform standards for defining who can practice as a midwife. Noncertified midwives -- traditional birth attendants, or TBAs -- also deliver babies in the United States. …