Midwives Popular, But More Forced out of Business

[bigmona]

Midwives Popular, But More Forced out of Business

Run Date: 12/12/03

By Asjylyn Loder

WeNews correspondent

Even as demand for midwives increases in the United States, many are being forced out of business, leaving pregnant women with fewer options.

(WOMENSENEWS)--The birth of Miriam Singer's fourth child was tinged with a sense of loss for the mother, who knew that she was among the last few who would deliver a baby at the midwifery center at the University of Chicago Hospitals and Health System, where Singer had delivered all of her children.

The hospital stopped accepting new midwifery patients in early October after 18 years, and will soon close its doors despite an outpouring of community support from loyalists such as Singer.

The demand for midwifery care has more than tripled in the last decade, but rising insurance costs have made it difficult for midwives to stay in business. Midwives spend more time getting to know patients throughout their pregnancy and are less likely to intervene by inducing labor or performing Caesarean sections. For those reasons, many women favor midwifery care. But midwives earn substantially less than obstetricians and hospitals and independent midwives alike are finding it hard to shoulder skyrocketing malpractice premiums.

Midwives attended 305,606 births in the United States in 2001, or nearly 10 percent of lady partsl births, a 100 percent increase from 1990, according to the National Vital Statistics Report by the Centers for Disease Control and Prevention. Studies have shown midwife deliveries to be as safe as physician-assisted deliveries. Of births attended by midwives, 97 percent take place in hospitals, where an obstetrician is on call to handle complications.

Singer, for example, suffered serious postpartum bleeding after the birth of her third child. Her midwife called in a physician to handle the bleeding, but stayed by Singer's side. Singer had a high risk of bleeding with the next delivery, but the midwife brought Singer safely through without complications while a physician remained on-call for emergencies.

Certified nurse midwives are typically registered nurses who have completed a Bachelor's degree, often in nursing, and earned advanced certification in the care of pregnant women.

Closures, Protests Around U.S.

There are no statistics on how many midwifery practices across the country have closed recently but several prominent midwifery services have been scaled back or closed since August.

On Sept. 29, Full Circle Women's Health, a nonprofit midwifery practice in Tallahassee, Fla., closed its doors after 20 years due to a rent hike and doubled malpractice insurance rates. In Des Moines, Iowa, a hospital that handles most midwife assisted births in the area cannot find enough physicians to meet the requirement that midwives work with two attending physicians and has let go four midwives as a result. In New Jersey, the last of three independent midwifery birthing centers closed in 2002.

New York saw an escalation of this trend this year. In August, the Brooklyn Birthing Center announced that its malpractice insurance had stopped covering midwives. Then, on Sept. 1, the prestigious Elizabeth Seton Birthing Center announced the closure of its Manhattan birthing rooms due to a 400 percent hike in malpractice insurance rates. In early October, New York Presbyterian Hospital initiated cutbacks in midwifery services at its Allen Pavilion branch.

Midwives displaced by the string of closings have found it hard to find a home elsewhere. In late November, four former Seton midwives quit St. Vincent's Hospital, complaining that hospital regulations--including a policy that advised recommending inducing labor six hours after membrane rupture--made it impossible for them to practice the methods of natural, noninterventionist childbirth that defines midwifery care.

As several high-profile midwifery services were forced to close their doors this year, women have rallied together to demand the greater continuity of care and attention that midwives provide.

In Austin, Texas, where hospital-based midwifery care was discontinued last year, midwives and former midwifery patients demonstrated in October to bring the midwives back, which may happen under new hospital managers. And in Chicago, midwifery patients marched on the University of Chicago Hospitals after it announced the closure of its midwifery practice.

Record-High Insurance Pinches Midwives, Doctors

Hospitals across the country are going through painful cost-cutting due to the rising costs of care associated with record-high insurance premiums. Even though midwives usually earn less than obstetricians, in lean economic times hospitals can be tempted to cut back on them and direct patients instead to obstetricians, because obstetricians are fundamental medical personnel. In addition, insurance companies often have lower reimbursement rates for midwives than obstetricians.

"The midwives are getting caught in the squeeze," said Deanne Williams, executive director of the Washington-Based American College of Nurse-Midwives.

Midwives earn on average $41,500 to $52,000 annually, topping out at $65,000, according to the University of Missouri Career Center--less than half of the $133,450 earned by obstetricians, according to the Bureau of Labor Statistics. The insurance plan endorsed by the American College of Nurse-Midwives costs from $7,000 to $32,000 per year, depending on experience, education and location. New York, and Florida are two of the priciest states to practice.

Obstetricians are also feeling the pinch with median premiums that increased 167 percent between 1982 and 1998, and rising steadily each year since. Last year, saw a 15 percent increase. Many doctors are choosing to close their practices.

The upshot is what many see as a triple negative for health-care participants.

"The loser is the physician who is overburdened, the woman who does not want to receive that kind of care and the midwife who is out of a job," said Williams.

Singer agreed. "Their availability is second to none. In terms of pre-natal care, I was able to call the midwives any time, the whole nine months," she said. Singer was able to see the same midwives through the births of all four of her children and the midwives stayed by her side throughout the duration of her labor, following her wishes to have a low-intervention delivery, qualities Singer doubts she could have found from a busy obstetrician.

"If I were to have delivered with an obstetrician, my delivery would mostly be attended by labor nurses that I didn't know and by residents," she said.

In scaling back its midwifery service, New York Presbyterian Hospital cited concerns over the safety of their patients, reclassifying "low risk" patients as "at risk," thus disqualifying them from midwifery care. Midwives counter that they have safely managed high-risk deliveries for years and that the maneuver is designed to force midwives out.

"We traditionally work with high risk populations and decrease the bad outcomes," argued Janet Brooks, who has been a midwife at Allen Pavilion for 14 years. "What they are saying is that they are changing to a medical model of care," she said. "A medical model of care means that there will be more interventions and the more interventions, the more money you can charge."

There is speculation that the change in policy is related to a $5.1 million Medicaid fraud settlement agreed to by the hospital earlier this year. The lawsuit alleged that doctors had fraudulently billed Medicaid for services performed by midwives.

Hospital spokesperson Bryan Dotson says patient safety, and not financial considerations, was the primary concern. He added that no midwives have been let go as a result of the new policy.

A late November study by American Baby magazine found that women attended by midwives were less likely to have a Caesarean and received less medication than women attended by an obstetrician. Statistics this year showed that 26 percent of babies in the United States are now delivered by Caesarean, in part because of guidelines by the American College of Obstetricians and Gynecologists that allow for elective Caesarean. The World Health Organization recommends a national Caesarean rate of 15 percent.

http://www.womensenews.com/article.cfm/dyn/aid/1635

[BabyRN2Be]

This is just really sad. Women are losing their choices in childbirth to the almighty dollar.

Forgive me if I'm stepping on anyone's toes. I know that OB/midwives have high insurance rates, but losing one's options for a pivotal life event is depressing

[Energizer Bunny]

This is just really sad. Women are losing their choices in childbirth to the almighty dollar.

Forgive me if I'm stepping on anyone's toes. I know that OB/midwives have high insurance rates, but losing one's options for a pivotal life event is depressing

Depressing to me too since I want to practice as a CNM.

[legsmalone, RN]

I am also saddened by this. One of the reason I went to school to be an RN was with the hope of becoming a practicing CNM. It is starting to look as though it would be a better choice to be an NP given the above article.

Unless of course attitudes shift and Insurance companies back off a bit and let people provide the care patients want.

[Dayray, RN]

It's looking bad for midwives and low intervention birth in general. Rising insurance costs along with the idiotic rules placing midwives in the position to have to beg physicans to be there back up, are pushing midwives out.

Allot of the people I've heard speaking at conferences are predicting that the C/S rate is going to be as high as 50% in the near future. It's much easier to defend a bad outcome from an "elective c/s" then it is to defend a bad outcome from an attempted lady partsl birth. Not too mention everyone gets to charge more for the C/S.

When the recommendation came out making elective sections OK, they said it was "a patient chose issue". In reality I think it was a way to limit liability and enhance profitability for the OB's.

Although there are a few people who use CNM's, our country just isn't comfortable with advanced practice nurses. I had a patient ask me the other day "why would anyone go to a nurse to do a doctors job?" I had another one tell me that she had chosen our hospital because we had doctors place epidural and the other hospitals let those "CNA's" do it. I explained that they were CRNA's and explained to her that they are specially trained and have masters degrees but the public just doesn't understand.

I also very often have PTL patients come in with spec grav of 10.30. After giveing them my talk about the way a pregnant body changes and that they need to drink 2 or 3 litters of water a day, they ask "why havent I ever heard that before?" and I always think "becuse your not going to a midwife".

Why do CNM's receive only 1/3 of what an OB does for prenatal care? because or country doesn't place as much value on care delivered by a "nurse" as it does on the same care if delivered by an MD.

Why is that? well I'm sure there are allot of reasons but I can think of 2 right off the bat.

1 the AMA is one of the biggest lobbying entities in the country. The AMA is not going to allow other care providers to muscle in on their monopoly of health care.

2 the media,

people don't even know what nurses are. I can't count how many times I've had people make comments to me about bedpans (as if thats the biggest part of my job) or had first time parents shocked and asking "when is the doctor going to come?" because they don't know what we do. They don't know that I call the doctor and tell him I need orders for x,x and y or that I do my best to keep the doctor from cutting them just so they can make a dinner appointment. they think we only do what the doctor asks and clean up poop and pee. The biggest reason for this is the way we are portrait in the media.

I'm still considering going back for some kind of advanced practice. I really want to get more education. I'm just not sure its worth it. I really like the idea of what CNM's and NP's are supposed to be and perfectly capable of being but I see them struggling around me and in the end they are make less money, work harder hours and have more liability then I do as an RN.

[Energizer Bunny]

I wanted to share a little about the practice that I go to for all of my OB/GYN needs. There are two midwives there working completely WITH the dr's. I very rarely ever seem to hear of this and mistakenly thought it was becoming more commonplace. These people are fabulous!! The dr. that has the practice has been my dr. all along and he is a dear. He LOVES the midwives and supports them in every way.

When I had my first son, I had the dr's because the midwives were just coming on the scene and I really did not have a very good delivery (I'm not blaming it on the dr. just stating facts). It was a 40 hour labor, with three hours of pushing and the dr. was waaay tired, just coming off vacation and he and my husband stood there making jokes in between pushes. He was not very supportive either and I was upset that my "regular" dr. wasn't the one on call.

When I got pregnant with my second, I pretty much decided that the midwives were who I wanted delivering my baby and I want to tell you what a fabulous thing they are! My husband was working out of town five hours away when I went into labor and the midwife was right there with me. She told me that she wouldn't break my water until he got there and she was very supportive of me having an epidural. I never asked her to hold off on breaking the water and keeping things moving. She just KNEW how important it was to me. It was a fabulous 14 hour labor with 20 minutes of pushing and my baby girl just came right out.

My third, there was no question about having the midwives. It was a long drawn out process. By the time they decided to induce me, I was two weeks overdue and the induction went for 2 days before they decided to use Pitocin. Once they did, it still went another two days before I delivered, but not once did they give up on me. They did have the dr. there to break my water on the last morning and then called him when I was pushing because they were afriad of shoulder dystocia, but I never saw him other than when he broke my water. When I was at 6cm they called for bloodwork because they were afraid he wasn't coming, but they hung in there with me knowing I really didn't want a c/s unless absolutely necessary.

Okay, so my point with all of this is that the CNM's and Dr.'s work together completely . In this practice, the Dr's are just there to back up the midwives if there is a problem. Now I am having some bleeding problems and have had to go back to the dr. himself because of tests, etc. but I will definately do all of my regular preventive care with the midwives. They are also finding that in this area, more and more people are going to that practice specifically for the midwives. Heck between my last two kiddos, I moved almost an hour away and stuck with them when I am much closer to a lot of other dr's and a different hospital. I just wish I would have been here with the midwives when I had my miscarriage instead of out traveling with Bryan.

So, I guess I just wish that everyone could see midwives the way that my dr. does and the people in this area. So sad that they don't.

[bigmona]

I recently saw a midwife for my yearly check-up. I told her about my own plans to be a CNM but also raised my concerns about malpractice insurance and how that's causing me some uncertainty about pursing midwifery. She told me that the rates are high but not as high as they could be- docs have it much much worse and that it really wasn't as bad as people think it is. She works in a clinic that is completely run by midwives. I am pretty sure they do all their births in a hospital but it seemed to me they are all very happy there and happy with their situation and they have a lot of autonomy.

[Energizer Bunny]

I recently saw a midwife for my yearly check-up. I told her about my own plans to be a CNM but also raised my concerns about malpractice insurance and how that's causing me some uncertainty about pursing midwifery. She told me that the rates are high but not as high as they could be- docs have it much much worse and that it really wasn't as bad as people think it is. She works in a clinic that is completely run by midwives. I am pretty sure they do all their births in a hospital but it seemed to me they are all very happy there and happy with their situation and they have a lot of autonomy.

Well that's good to hear! :) I was planning on discussing this with my midwife too when I go back to see the dr. about my problems I have been having. They have always been really supportive and frankly, I am hoping that one of them will be near retirement when I finally graduate! LOL! Or, that the practice will need one more!

[gypsyatheart]

Excellent post Dayray!!!

It's looking bad for midwives and low intervention birth in general. Rising insurance costs along with the idiotic rules placing midwives in the position to have to beg physicans to be there back up, are pushing midwives out.

Allot of the people I've heard speaking at conferences are predicting that the C/S rate is going to be as high as 50% in the near future. It's much easier to defend a bad outcome from an "elective c/s" then it is to defend a bad outcome from an attempted lady partsl birth. Not too mention everyone gets to charge more for the C/S.

When the recommendation came out making elective sections OK, they said it was "a patient chose issue". In reality I think it was a way to limit liability and enhance profitability for the OB's.

Although there are a few people who use CNM's, our country just isn't comfortable with advanced practice nurses. I had a patient ask me the other day "why would anyone go to a nurse to do a doctors job?" I had another one tell me that she had chosen our hospital because we had doctors place epidural and the other hospitals let those "CNA's" do it. I explained that they were CRNA's and explained to her that they are specially trained and have masters degrees but the public just doesn't understand.

I also very often have PTL patients come in with spec grav of 10.30. After giveing them my talk about the way a pregnant body changes and that they need to drink 2 or 3 litters of water a day, they ask "why havent I ever heard that before?" and I always think "becuse your not going to a midwife".

Why do CNM's receive only 1/3 of what an OB does for prenatal care? because or country doesn't place as much value on care delivered by a "nurse" as it does on the same care if delivered by an MD.

Why is that? well I'm sure there are allot of reasons but I can think of 2 right off the bat.

1 the AMA is one of the biggest lobbying entities in the country. The AMA is not going to allow other care providers to muscle in on their monopoly of health care.

2 the media,

people don't even know what nurses are. I can't count how many times I've had people make comments to me about bedpans (as if thats the biggest part of my job) or had first time parents shocked and asking "when is the doctor going to come?" because they don't know what we do. They don't know that I call the doctor and tell him I need orders for x,x and y or that I do my best to keep the doctor from cutting them just so they can make a dinner appointment. they think we only do what the doctor asks and clean up poop and pee. The biggest reason for this is the way we are portrait in the media.

I'm still considering going back for some kind of advanced practice. I really want to get more education. I'm just not sure its worth it. I really like the idea of what CNM's and NP's are supposed to be and perfectly capable of being but I see them struggling around me and in the end they are make less money, work harder hours and have more liability then I do as an RN.