One of our families favorite things to do is check out old cemetaries - my kids love to read gravestones and talk about the stories that came behind them. I love cemetaries - I find them comforting in an odd way, although I'm not fully sure I can explain why, and I'm glad that my children have the same passion for historical records and also the same pleasure in knowing something about lives before ours.
Walking in old graveyards is also always a reminder of how fortunate I am. Most graveyards have a "children's" section, or family stones record the brief and incredibly short lives of children - and a world where losing at least one child was a norm. Add in the high risks of childbirth and a walk through a cemetary can be a laudable reminder of things one doesn't want to lose in a lower energy society - childhood vaccination, clean water supplies and good reproductive medicine - low technology whenever possible, but high when truly needed.
Moreover, for those concerned about population, counter-intuitively, demographers generally find that the conditions necessary for people to choose fewer children include radically lower child, infant and maternal mortality. Because childbearing decisions are often built on economic necessities, the less certain you are your children will live to adulthood, the more likely you are to have more of them. A longer term stability depends on keeping child, infant and maternal mortality low, even as we struggle with health care costs and the creation of a lower-energy infrastructure.
Over the last thirty years, infant and maternal death rates in childbirth in the US have crept up - in 1987 the death rate in childbirth was 6.6 deaths per 100,000 live births while by 2006 it was 13.3 - it had doubled. Some of this was probably attributable to better record keeping and reportage, but there's no question that the infant and maternal death rate in the US has climbed quite dramatically - even though it remains low compared to the Global South. In the same approximate period, however, enormous gains were made (although there is still much more to be done) in reducing child and infant mortality in the Global South - only in the US were we headed backwards.
For women of color, the rates of maternal and infant death, or serious and long-term health care consequences from childbirth are four times what they are for white women in the US. Two African-American women die in childbirth every day in the US - a rate that is truly scandalous. And compared to most of the rest of the Global North, the rates are extraordinarily high.
It would be easy to say that by necessity a lower energy and poorer world must result in worse outcomes for women and children - but there's some real reasons to question this. One way to look at this (and I do this in much more detail in my book _Depletion and Abundance_) is to ask whether it is possible to keep maternal and infant mortality rates low while using low-cost, lower energy interventions much of the time. We already know that many nations that have higher rates of home and midwife attended births have as good and better outcomes than the US. We also know that the Old Order Amish, who have what most of us would describe as high risk factors for perinatal death and injury - most women have many children, often continuing to have babies into their mid-forties or later, physician medical care is usually involved only if an emergency occurs, while most prenatal care is provided by Amish lay midwives at home in houses without electricity or often, running water, and most households do not have easy car access to transport women to the hospital. Despite this, studies suggest that rates of infant and mother mortality for Amish women are similar to white rural women in more modern settings.
This, and the experience of less wealthy nations with low infant mortality like Cuba might be used as a model to create a low-energy infrastructure that could further reduce infant and child mortality, a functional "shadow" health care system that could both reduce loss of life now, and also serve families in a world that may struggle even further to provide adequate health care access.
Amnesty International points out rightly that maternal and infant health care are a human rights issue - none of us want to live in the bad old days, when women made their wills before childbirth and cemeteries were filled with the memories of babies and children and women's lives cut short. None of us want to live in a world where preventable consequences of childbirth disable women and children and make it impossible for them to live a functional life. What's most disturbing about the growing rate of women struggling with health care issues is that it is so obviously possible to prevent most of those problem, most of them at low cost and with comparatively simple interventions.
Sharon, this was a really interesting post, thank you.
I'm in Canada so I don't know how comparable the statistics are because of our different health care system. But certainly the idea of low cost, lower energy interventions is something that could be relevant here as well.
I'm wondering about the increase in mortality rates that you mention. Do you think that any of this could be attributed to higher risk pregnancies as well? There have been considerable advances in reproductive technologies since 1987, so I'm wondering whether some of the resulting high risk pregnancies is what is also attributing to the trend upwards in mortality rates. Just a thought, wondering how you would understand this.
Thanks and please keep up the great posts. I don't often comment but I often share!
Jennifer -- you're right that the increase in high risk pregnancies may be a factor. Another thing to consider is the increase in obesity, which is itself a fairly significant risk factor. (You want to gain weight when pregnant, of course, but if you start out a hundred pounds overweight, you have a greater risk of complications for both yourself and the baby.)
Another factor that might be a little surprising -- an increase in technology to try and save the most fragile newborns. We want to save babies, of course, but one unintended consequence is a shifting of what category a particular death might fall under. Our system strives valiantly to save babies at 24 weeks, and this is a good thing on the face of it; there are babies born that early who have survived and done very well. But most of them have not, and this has moved them from the category of "stillbirth" to "neonatal death". I think it's generally good we try and save these children, and good we try to improve our ability to do so, but in the near term it means we're not necessarily comparing the same things in our statistics. I'm not sure what the actual impact of that is; it would take somebody who knows what they're doing to go through the records and do the right statistical analysis to figure it out. But my gut feeling is that it probably is a factor. (I doubt it accounts for all of it, and I don't think it would account for maternal mortality changes; I don't think there's been a similar category shift that might put women into the "maternal mortality" category or pull them out of it without actually changing the total number of deaths.)
It's certainly true that we have a massively inefficient health care delivery system in the US. When labor and delivery can be accomplished with minimal intervention, the outcomes are best. The hard part is that when things go badly, they tend to go badly very quickly and very seriously; do you want to gamble that your delivery will be one of the 90% of perfectly ordinary ones, or the 10% that give people nightmares? (Numbers pulled out of the traditional spot for blog commenting: thin air. AFAIK, the vast majority of deliveries will be uncomplicated, though. The hard part is predicting which ones those are.)
My personal feeling (as a total non-expert) is that the answer probably involves birthing centers attached to hospitals, where women can labor and deliver in comfort and in close proximity to highly qualified medical care in the event things go south. It could be much more efficient, more cost-effective, and safer for all. But I suspect it won't happen in the near future, because to get this sort of thing rolled out nationwide we'd need a serious government investment in it, and right now that's practically a vulgarity in American politics.
I have two additional caveats about the rise in mortality rates:
1. I've heard that if a woman has a botched abortion but doesn't die until after leaving the abortion clinic, it is counted in the maternal death rate.
2. We've suspended natural selection. As we save more women who have difficult childbirths, the proportion who have those issues go up.
I totally agree that I do not want to see infant and maternal death rates return to their previous levels.
John, your concern about botched abortion is not relevant. Data consistently demonstrates abortion is actually safer than carrying a pregnancy to term. When this was initially discovered during the days of Surgeon General Koop he created a political scandal when he tried to supress the data. Abortion is safer than pregnancy by about 50%.
Calli, you are correct that some of the death rate in this country might be because we actually have earlier viability dates than other countries. We try harder to save increasingly younger and smaller premies. I see a lot of these kids in my training as peds surgeons are often consulted on these kids for one of their most deadly and common complications, NEC, or necrotizing enterocolitis. The value of pushing this boundary might be questionable. The more time kids grow outside the womb, the worse their long term health prospects, and they have dramatically increased rates of potentially devastating complications such as intraventricular hemorrhage. You do a lot of work and the ultimate quality of life might be poor. However, we don't push the boundaries for nothing. Lot's of kids, even the smallest premies with severe IVH and NEC turn out OK, and you can never tell which will be the lucky ones.
Finally, a state-by-state analysis of infant mortality provides additional data on where the problem may be. In the poorer states, appalachia and the south, the infant mortality rates are 2-3x higher than they are in Massachusetts or California. The infant mortality in the blue states as an aggregate tends to rival that of great Britain or the Netherlands. However, states such as Mississippi have infant mortality rates equivalent to some third world nations, in the 13/1000 live births range. See this map here for a state by state comparison. As you can see, proximity to the Mississippi river seems to correlate with a doubling of the infant mortality rate. This is poverty and poor health care access. It also correlates with obesity rates interestingly enough, so maybe Calli has another point right there.
It is true that technology is reshaping some of this - the rate of maternal death is probably less closely related to rising ages than other things - the population that is most likely to die hasn't seen the same levels of increase in fertility treatments and older age pregnancies, but I'm sure it is one of the factors in a small way, as is the technological intervention.
The rate of death from abortion is so radically smaller than the rate of death due to childbirth that "botched abortion" is not meaningfully affecting the statistics.
Don't forget older mothers. Mostly not a big factor, but a factor none the less.
A lot of what is considered "common knowledge" about maternal and perinatal mortality is actually not true. The same thing applies to midwifery outcomes.
1. Infant mortality is a measure of pediatric care, encompassing as it does death from birth to one year of age. According to the World Health Organization, the best measure of obstetric care is perinatal mortality (late stillbirths + deaths up to 28 days). According to WHO data, the US has one of the lowest perinatal mortality rates in the world, which is particularly notable because we have a higher risk population and no universal health care.
2. The CDC estimates that most of the purported increase in maternal mortality is the result of improved assessment tools. Indeed, a major proportion of the increase occurred in the immediate aftermath of the 1999 and 2003 revision of the standard death certificate. States that have not yet adopted the new standard death certificate have experienced no change in maternal mortality.
3. Contrary to the assertions of midwifery and homebirth proponents, the vast majority of maternal deaths occur in women who have pre-existing medical problems or serious complications. Preventing maternal mortality among these women requires more technology, not less.
4. The country with the higest rate of homebirth in the industrialized world, the Netherlands at 27% and falling, has one of the highest perinatal mortality rates in Western Europe and a high and rising rate of maternal mortality. Indeed the Dutch government has been actively investigating the problem.
Although studies of homebirth with a Dutch midwife show equivalent mortality rates to hospital birth with a Dutch midwife, it has become apparent that midwives have higher than expected mortality rates. Indeed, a recent study showed that low risk birth with a Dutch midwife (home or hospital) has a HIGHER perinatal mortality rate than high risk hospital birth with a Dutch obstetrician!
5. Certified nurse midwives (CNMs) provide excellent care, but very few are willing to work outside of hospitals because of the increased risk of death at homebirth. According to the CDC data, homebirth with a CNM has double the mortality rate of hospital birth with a CNM.
6. Most American homebirths are attended by a second class of self-proclaimed midwives known as lay midwives, certified midwives or licensed midwives. These women are typically high school graduates with NO formal education in midwifery. Instead they have complete a self-monitored course of independent study. They are ineligible to practice as midwives in the UK, the Netherlands, Canada, Australia or anywhere else in the industrialized world, because they lack the college level degree required of midwives in ALL other first world countries.
The latest CDC data shows that planned homebirth with a non-nurse midwife has a neonatal mortality rate more than 600% higher than comparable risk hospital birth. In every state where statistics are available homebirth with a non-nurse midwife has anywhere from a 100%-300% higher rate of neonatal mortality.
In light of the above factors, neither midwifery care nor homebirth are the solutions to the problems that we face in lowering mortality rates.
great info bro
Looking over the data on the Netherlands, for the moment, there is no absolute rise in infant mortality - that is, the rates aren't going up - merely a slower decline rate and a rise in the European rankings - ie, not declining as fast as some counterparts.
None of the papers I can find (this is nice representative one) suggest that midwifery and home birth are major factors in either maternal or perinatal mortality - the statistically meaningful issues differences tend to have more to do with immigrant populations, older maternal ages and more multiple births than other european countries. http://www.demographic-research.org/Volumes/Vol11/13/11-13.pdf
It is absolutely true that homebirths generally seem to be associated with a small rise in infant mortality, and I don't intend to trivialize that - but the meta-analysis in AJOG itself suggested that in large part the difficulty could be resolved by better training of midwives in handling breathing difficulties at birth. Most of the CNMs I'm aware of don't practice at homebirths because of the incredibly onerous insurance and regulatory issues, not because they don't want to.
Regardless, in a lower energy, poorer, hotter society, high input, high cost, high technology responses are increasingly hard to come by for a lot of people - we can choose to pretend that isn't true - that people don't choose homebirth because they don't have insurance and can't afford a hospital birth, or we can work to make it possible to avoid the worst outcomes even when access to some things is restricted - and potentially increasingly restricted.
Sharon- Thank you for your measured response to Dr. Tuteur. For those who don't know, Amy Tuteur is a professional internet concern troll, whose sole mission is stopping homebirths. I find that particularly vexing here as this isn't a site on childbirth but on energy depletion and related emergencies, crises that may very well have the affect of forcing lower input deliveries (and indeed more homebirths) whether we like it or not. Amy Tuteur's one track mind serves her particularly poorly here.
The issue of reductions in medical care due to powering down (or other reasons) reminds me of a report I saw on the news the other day.
Basically, there is a serious problem providing chemotherapy drugs to cancer patients, due to manufacturers making less of them, mostly because many of these drugs have gone off patent. The report focused on children with leukemia, but this is a serious problem for many cancer patients, as well as people who take these drugs for autoimmune disorders and the like.
Like many other types of medical care, loss of cancer therapies is something we don't want to experience as we power down.
Concern troll or not, the most-convincing data I've seen demonstrates about a 2 fold increase in risk in neonatal mortality for home birth versus higher rates of intervention and maternal complication in planned hospital birth. Part of the reason many things appear worse in the in-hospital data set are that any complication detected by screening is going to result in a hospital birth versus a home birth as nurse midwives will not deliver infants with high probability of complications. This should, however, mean their general rates of complications should be lower, and for many things they are, such as perineal tears in moms, low birthweight babies, etc. But it should also mean their neonatal mortality is lower since they've selected for moms that passed prenatal screening without detected abnormalities. This is not the case. Neonatal mortality is doubled.
Certainly, the presence of a midwife is better than no midwife and it is less costly. It also is often a matter of individual preference of the mom, and that's fine. However, a pre-requisite enforced by the midwives should be adequate pre-natal screening (and this is the case in the states in which I've worked. Also, they should understand that at home births are a higher risk for the infant. This risk may be acceptable to individuals as the mom may feel the benefits outweigh those risks.
I have seen deliveries go bad fast. I've seen term women being monitored show sudden loss of the infants vitals, and I tell you, the OB's can put general surgeons to shame in terms of "decision to incision" time. We were in the OR making the incision in under 10 minutes and they got that baby out.
There is just no way, even attached to a hospital, a midwife will get that speed of response to an emergency that can be achieved on an OB ward. And I don't think you can call a doubling of neonatal mortality a small increase.
The rising rate of cesarean section, now almost one in three births in the U.S., also contributes to increasing maternal mortality rates. Surgical birth can save lives and health, but unnecessary cesareans -- falsely promoted as easier and safer than vaginal birth -- are much more risky for both mother and infant.
Sharon's post wasn't about encouraging homebirth- it was, instead, pointing out the distinct possibility that more homebirths may be in our future whether we like it or not, and musing on how we can make them as safe as possible. That's all, and jumping into speeches about how hospital births trump home ones in terms of safety, how more technology is a good thing, just seems unproductive, given the parameters of the discussion. Imagine, if you will, a world in which many hospitals have been shut down due to lack of funding, and the ones that remain are overcrowded and understaffed, with limited equipment- is your average low risk woman really better off giving birth there than at home, particularly if she has to travel a long ways to get there? And maybe this grim scenario won't be our future, but I think it's worth considering all the same. Giving hospitals 100% of the power to deal with births makes me uneasy because of these possible future implications.
And yet the perinatal and maternal mortality rates in Amish communities, using lay midwives are much less than double - moreover, the Canadian matched outcomes study (useful because it showed the same midwives doing similar births in hospitals and at home) showed no difference in outcome. http://www.cmaj.ca/content/181/6-7/377.abstract A recent Swedish study found a slight increase, but concluded the results weren't statistically significant.
I'm not a passionate homebirth advocate- all of my own children were hospital or hospital birthing center births. (I am chronically group-b strep positive and chose to give birth where I could have Iv antibiotics) My first birth was OB attended because my son was transverse until shortly before delivery (flipped on his own after a failed version), the other three were all CNM midwife attended hospital or hospital-birthing center births. (I will say that the difference in quality of care and birth experience between midwives and OB was night and day, and if it is selfish to prefer that when you are in the most pain of your whole life you have a non-shitty experience, well, color me selfish.) Frankly, I never had any desire to have a homebirth personally - for my first it wasn't an option, for the later ones the idea of being home near the laundry and the kids wasn't that appealing ;-). Others obviously feel differently.
I don't see advocacy about home birth as my central premise in arguing about the shape of reproductive health to come, but I do think that the hostility to homebirth that comes from Dr. Tuteur (whose writings I've now looked up) seems strange to me. The rhetoric there (and to be fair the rhetoric of the ACOG) is that women who choose homebirth are selfish, fundamentally, valuing the "birth experience" over the life of their children.
And yet we do respect women's right to make choices that raise their risk of maternal and infant mortality - we don't, for example excoriate or prohibit pregnancy in women over forty. We don't do the same for women who seek out fertility treatments that raise the likelihood of multiples, even though that raises the risks much higher than homebirth with a midwife. We don't demand that women move out of poor rural and urban areas that slow their access to health care. We don't demand that they induce during working hours, despite a Scottish study that found a similar doubling of risk for women who give birth on off hours and on the weekends.
Most women I know who gave birth at home did so because of one of two things - the high cost or the speed of their previous deliveries (in fact, I have a close friend whose second baby was a successful home birth and third baby was a successful (in that the baby was healthy and so was Mom), if hardly desirable, car birth, since she didn't make it to the birthing center on time - the difference was that during the third pregnancy her husband was no longer unemployed, and insurance would cover the birthing center birth, but not the homebirth - even though given her previous history of extremely fast deliveries, the better outcome would have been a homebirth (which probably couldn't help but be safer than delivery in a parking lot by one's untrained spouse on a freezing January night). Another woman I know chose midwife-assisted homebirth because she can't afford to have a c-section - she was on her first birth, and she knew that a c-section would break them financially (indeed, in the US bankruptcies and foreclosures correlate heavily with medical bills), and moreover, would preclude their ever having another child, given the then-radically increased odds that she'd have to have future c-sections. Perhaps her choice was wrong - but it wasn't driven by romanticized birth experience dreams, but by hard realities that aren't getting any better for most of people.
Failing to acknowledge the affordability issue and the fact that no insurance I know will give a fast-delivering woman carte blanche to move into the hospital and framing it entirely as a selfish desire to have a particular kind of birth experience seems disingenuous to me.
Moreover, for most women the consequences of childbirth that concern them are less death of mother or child (whether that is right or wrong, both are rare) - which probably is a minute concern for most women, but the other consequences of childbirth - "is associated with a shorter recovery time and fewer lacerations, post-partum haemorrhages, retained placentae and infections" (from the lancet). Add in the risk of c-section in a hospital birth, and there's a considerable incentive here to take some mild risks - and it isn't just selfishness. The longer recovery time of a c-section is often tough for women who are worried about losing jobs or are their family's primary supports, or for women who are rightly worried about the long term pain and sexual consequences of an episiotomy or other pregnancy complication - these can be really miserable.
There's something about the rhetoric of this that reminds me strongly of anti-abortion rhetoric - the implication being that women should make any sacrifice of their health, economics, and other well-being for the sake of their babies. I don't know that that's intentional, but I do find it troubling. On Dr. Tuteur's site, there's an awful lot of "they killed their baby because they are hippies who wanted a loving birth experience" - baby killer is pretty laden language, and the idea that women selfishly kill their babies for their own desires has an echo in the anti-abortion movement - it bothers me that the anti-homebirth movement is using that same language.
Again, without in any way trivializing the concern about raised rates of perinatal mortality, it is worth asking are there any other ways to reduce those risks acceptably, and also why the double standard of hostility towards one set of choices that women make that do raise risk, but not others? I don't think we will be getting rid of homebirth - because barring a society that provides full free medical care, barring a cheap oil society and economy we can't count on, women will choose the lower cost experience, they will choose the one that seems safer when they deliver quickly, they will choose the one they can afford, they will choose the method that reduces their risk of permanent sexual injury or long term dependency of c-sections - indeed these things are only going to increase. Given that the main risk seems to be dealing with infant breathing difficulties, it seems prudent to me to figure out more and better ways to deal with this in the home for the probably increasing number of women who will make that choice for a whole host of reasons that seem pretty reasonable to me.
We have some appalling statistics in this country for maternal mortality. We spend more than any other country in the world on health care, yet 40 countries do a better job. Our obesity epidemic, leading to hypertension and diabetes, puts more women at risk of complications during pregnancy, delivery and the postpartum period. Our rising cesarean section rate is also contributing. Women who deliver by cesarean section have higher rates of morbidity and mortality than women who deliver vaginally. Women who have multiple cesareans have greatly increased risks of placental abnormalities which can cause hemorrhage, hysterectomy and death. Deaths from preeclampsia/eclampsia are also on the rise. Regardless of income, four times more black women die from pregnancy, deliver prematurely or produce more low-weight babies than white women in the US. We could definitely do a better job.
One other point just came to my mind -- the definition of "neonatal mortality" is different in different countries, so be wary of comparing statistics. The definition of "infant mortality" is generally any death under one year of age, but many countries call it a "stillbirth" if the baby dies within the first day or is under a particular gestational age; in the US, pretty much any signs of life will get it marked as a live birth, which means that if the baby dies shortly thereafter, it goes into the infant mortality statistics. In many other countries, that baby would be recorded as a stillbirth (in those countries which record stillbirth).
We were in the OR making the incision in under 10 minutes and they got that baby out.
There is just no way, even attached to a hospital, a midwife will get that speed of response to an emergency that can be achieved on an OB ward. And I don't think you can call a doubling of neonatal mortality a small increase.
I think it may have been even faster with my first. The baby's heartrate dropped off the monitor entirely (and we were on an internal monitor at that point); going on hands and knees to relieve weight on the uterine arteries didn't help; an OB I'd never seen before came in, calmly assessed the situation, and called for a c-section. The nurses immediately went into motion, calmly but efficiently and precisely. While wheeling me into the OR, one was doing a sort of stripped-down presurgical consult, asking me the usual questions about breathing issues, heart issues, allergies, etc. The moment we got in, they were cleaning my belly, taking my glasses, and the anesthesiologist was putting a mask over my face. I was really impressed by the combination of calm and speed that was displayed; they knew precisely what they were doing. It was like watching a drill team perform. I rather suspect they had me open within seconds of my falling asleep. My mom reports watching them wheel me out of my room (she could see from the waiting area) and into the OR, and then, before she'd quite processed what was happening, a baby being wheeled back out. :-D And the baby was screaming -- nobody has any idea what actually caused her pulse to stop, because she was fine when she came out. I like to joke that she grabbed the umbilical cord and pulled it like the cord on a bus that you pull to say you want out. :-D
The hospital where I delivered both of my children (both via c-section) has a birth center. It's actually physically in the building. Both times, alas, it was full and I was admitted to the regular OB ward instead. That ended up being fine since of course I didn't get to labor much anyway. ;-) The main upshot of it is that you get to stay in the same room throughout your labor and delivery and recovery, barring need for a c-section. And they are truly awesome in their care. The birth center is across the hall from the OB ward, and the ORs are in the middle between the two. Both are served by a full hospital staff, as needed, but there's more privacy in the birth center, which has a more homey interior design philosophy. Adjacent to the birth center is the NICU. What's more, this hospital is attached to a children's hospital, with labor and delivery sort of in the middle; the NICU is actually run by the children's hospital. That's what I mean when I talk about a birth center attached to a hospital -- I mean, attached to the point where you can go from your room to the OR in under two minutes, and where there are OB/Gyns and pediatricians and anesthesiologists on hand at all times. That seems to me to be an ideal situation. But it's also expensive, which is why very few hospitals are set up like this, and why I don't think we'll see such a thing become widely available, especially to the poor, without a substantial government investment.
Quick question for you: when you say that a homebirth or midwife-assisted birth is generally the cheaper option, how much does it generally cost in your area? We're trying to get pregnant, and I've been looking into our options. The midwife nearest us charges $3000. The midwife birthing center we'd really like to use charges $7000. They claim to have a sliding scale, but it would have to slide a lot for us to afford that! We may be left with no option but a hospital birth, which I really do NOT want to do. Is it only in our area of the country where homebirths and midwives seem to be becoming features of yuppies and the upper middle class? It would be ironic indeed if, in the future, poor women delivered at the hospital while those with money did so at a birthing center or in the comfort of home.
After my comment yesterday, I did some more research, and it turns out that right now midwife-assisted births are becoming something only the well-off can afford. Women in some parts of the country can pay up to $8000 for a home birth attended by a midwife. This is a true birth at home and not at a birthing center. From what I read, the average is about $5500. I'm not blaming the midwives; they have to make a living, after all, and I'm sure their insurance premiums are sky high, but it is what it is.
Naturally, the vast majority of insurance companies won't cover home births or births at birthing centers, so that means most women do have to pay for this out of pocket. It's claimed that home birth is cheaper than a hospital birth and that's true -if you have to pay for it yourself. But, every insurance company covers the majority of the bill for hospital births; mine only has a $300 copay. And every state has a Medicaid program for low-income women that will completely cover the hospital bill(s). (Tennessee is the odd duck out: their Medicaid program will also cover a midwife's bill.)
Right now, this leaves the majority of low-income women (who are, of course, the majority of women) with no choice but to go to the hospital. Fast forward to an era where insurance companies are cutting benefits and Medicaid is no more. If midwives are still charging these kinds of fees, what does that mean? It means that most low-income women will go back to the days of unassisted childbirth, and use the hospital only as an emergency backup. This will, naturally, result in a dramatic increase in the maternal and neonatal death rate and (our country being what it is) a probably useless law banning homebirths.
How can we fix this?
Rebecca, I'll have to ask my friends who have had homebirths. I know that the local Amish midwife charges on a sliding scale, but I think it is around 800 for all prenatal care and the birth. I don't remember how much other people have paid over the years, although I know they told me and it was significantly less, but I don't remember how much (most of my same-agish friends have school-aged kids now, given that we're all late 30s to mid-40s, so this is also a few years ago).
I want to point out that the only reasons maternal mortality rates are low are technological. In an environment with war, poverty, and minimal technology, lifetime maternal mortality rates rise to around one in eight. The most useful interventions are Pitocin for hemorrhage, magnesium sulfate for preeclampsia, sterile equipment, and a trained skilled birth attendant. These are all going to need to be priorities if we wish to keep those low rates.
If midwives are still charging these kinds of fees, what does that mean? It means that most low-income women will go back to the days of unassisted childbirth, and use the hospital only as an emergency backup.
I'm a grandad with an interest.
Your original piece gave a reference to an early 90s study of Amish. A quote from a 2009 thesis "While having
more pregnancies than Central Pennsylvanian women, the Amish exhibit equal incidences of low-birth weight infants and preterm delivery and half as much stillbirth." google jennifer stuart amish women 2009
Also for a 2007 study of Amish women's reproductive health google Miller Hillemeier 2007 Amish Pennsylvania
PS Only being 5 min from hospital for a mid-wife attended home birth in UK (free universal health care) saved our daughter when things went suddenly very wrong. Extremely rapid Caesarean saved daughter and rapid surface transit 100 miles to fantastic centre of excellence saved grandaughter with no subsequent damage - still some residual risk because she is only two. A lot of the rescue kit is not that hi-tec but preserving both high skill and access at local levels could be big future issues.