Can Midwifery Balance the Budget?
By Marilyn Greene

	It would be simplistic to look towards only one group to accomplish a
task as monumental as balancing the United States budget.  It will take the 
combined effort of all Americans, including midwives.  What can the
profession of midwifery do to help in this enormous undertaking?  It is the
purpose of this paper to illustrate ways that the training, promotion and 
utilization of midwives will reduce costs in this increasingly more expensive 
aspect of the American health care system.
	In the last twenty years, a renewed interest in midwifery has 
produced an abundance of books and articles.  Several historical researchers 
have presented a different perspective of the midwife.  Negative propaganda 
aimed at eliminating midwifery practice and competition was generated by 
special interest groups and spread by the media in the early part of this 
century (Litoff, 1978; Wertz, 1997; Ge'lis, 1991).  Along with this renewed 
interest in the historical aspects of childbirth came literature written with 
anthropological, social, feminist and populist themes.  These books explore 
the social aspects of midwifery care (Michaelson, 1988; Mitford, 1992; 
Kitzinger, 1991), while other books and studies focus on midwives safety 
records both at home and in birth centers (Tew, 1990; Rooks et. al., 1989; 
Durand, 1992). 
	How will this reaffirmation of the many benefits of midwifery care 
help reduce costs here in the United States?  In Pursuing the Birth 
Machine, Marsden Wagner describes two different approaches to childbirth 
in this country.  One is the medical model with its close association with 
technology and intervention.  Inherent problems of this model include a high 
rate of intervention, including cesarean sections and large numbers of 
litigation suits.  The other approach is the social model.  The social 
approach to childbirth encourages community involvement, increased use of 
midwives and limited use of technology.  In Mr. Wagner's opinion, the way to 
fix the problems is to decrease the use of the medical model and increase the
use of the social mode.  He has written his book to assure that this 
philosophy of childbirth is heard over the clamor of the current "Birth 
Machine" that aggressively promotes the medical model of childbirth without,
in most cases, scientific data to support its practices (Wagner, 1994).
	Midwives have demonstrated their ability to avoid intervention and 
help reduce the problem of unnecessary cesarean sections.  Studies have shown
that women transferred to the hospital for cesarean section who were under
midwives care have a much lower c-section rate than usual.  One study of
outcomes of care in birth centers included a sample of 11,814 women with 80
percent having a midwife as primary attendant.  The rate of cesarean section
was 4.4 percent (Rooks et. al., 1989).  In another statistical evaluation of 
home birth, the 1,715 births managed by the Farm midwives in Summertown, TN
produced a cesarean section rate of 1.4 percent (Durand, 1992).  In
estimating cost savings in this one area, it has been proposed that by
reducing the United States cesarean section rate to 15 percent from the 1986
rate of 24 percent, we could have saved $1000 million in one year 
(Wagner, 1994).  The 1994 edition of Public Citizen's Health Research 
Group's publication Unnecessary Cesarean Sections: Curing a National Epidemic 
places the current cesarean section rate at about 22 percent.  By using a 
figure of 12-14 percent as an optimal range that was based on data from 
around the world, they estimate that 473,000 of the 966,000 cesareans in the 
United States in 1991 were unnecessary.  This overused procedure cost society
approximately $1.3 billion.  Researchers for the National Center for Health 
Statistics have published similar cost savings statistics (Gabay & Wolfe, 
1994).
	Savings that are by-products of a lower cesarean rate include more 
than just the savings in hospital costs.  They also include decreased use of 
expensive neonatal care units and may reach into the home.  Loss of earnings 
and the expense of extra help at home while recovering from surgery are other
"hidden" costs.
	A second area that could produce cost savings is the location of 
childbirth.  An average cost of complete home birth care with a midwife is 
from $900 to $1,500.  Hospital costs for an uncomplicated vaginal birth start
at around $5,000.  Holland which has 38 percent of its babies born at home 
also boasts a 4 to 5 percent cesarean section rate.  The Nordic countries of 
Finland, Sweden, Denmark and Iceland have perinatal mortality rates 
significantly lower than the United States.  The Dutch system is based on 
mutual respect between midwives and doctors.  Midwives work independently, 
and these countries perceive childbirth at home to be safe and cost effective
(Randall, 1991).
If we use the figure of $1,500 as the fee for prenatal and home birth care 
with a midwife and compare it with the fee of $5,000 for a hospital birth 
with an obstetrician and multiply this number by 40 percent of the babies 
born in the United States each year, you would arrive at an estimated cost 
savings if women in the United states had home births at the same rate as 
women in Holland.  Even if you deduct from this figure to control for 
transports to the hospital, this is a large area for cost savings.
	Other areas that may benefit financially from the social model of 
birth is preventive health, health education information, teen pregnancy 
and the enormous cost of low birth weight babies.  Additional research needs 
to be done to see if midwives can help lower costs in these areas.  Also, we 
need to examine whether more midwives would equate to an increase in access 
to prenatal and birth care for more women.
	Just as all families will not choose to stay at home to have their 
babies, other families should not be forced by lack of education or 
availability of alternatives to choose an expensive and often technical and 
interventive hospital experience.   Other families may find comfort in the 
middle ground approach of a birth center.  In order for birth to be returned 
to the family and the community, many choices should be made available.  The 
Women's Institute for Childbearing Policy calls for "a national health 
program that recognizes the midwife as the appropriate primary care giver for 
most childbearing women and that provides broad support for widespread 
implementation of a midwifery approach to care." In their 1994 revised 
edition of Childbearing Policy Within a National Health Program: An Evolving 
Concensus for New Directions, the cost-effective qualities of primary 
maternity care utilizing midwives is discussed.  Studies of midwifery care
both in and out of hospital show major cost savings in many areas.  Midwives' 
fees were lower, it costs less to educate them, they are less likely to be 
sued, have lower intervention rates, their clients have shorter hospital and 
birth center stays and they are willing to work in non-hospital settings that
are the most cost effective.
	The cost of childbirth to both the individual and society is dictated
by many factors including location and frequency of intervention.  The 
purpose of this paper was to illustrate ways that the midwifery model of care 
could reduce childbirth costs.  In doing this, I hope that we will be a 
little closer to changing some of the problems that characterize what Jessica
Mitford calls "The American Way of Birth" or what Marsden Wagner refers to as
"The Birth Machine" in this country.  While midwives may be unable to balance
the national budget, they may be able to lead the country back to a 
sustainable health economy.

REFERENCES

Durand, M. A. (1992).  The safety of home birth: The
   Farm Study.   The Birth Gazette, 8(2). 13.

Gabay, M. & Wolfe, S. M. (1994).  Unnecessary cesarean
   sections: Curing a national epidemic.  Public
   Citizen's Health Research Group, 48-50.

Ge'lis, J. (1991).  History of Childbirth.  Boston:
   Northeastern University Press.

Kitzinger, S. (1991).  Homebirth.  New York:       
   Kindersley.

Litoff, J. B. (1978).  American midwives: 1860 to the
   present.  London England: Greenwood Press.

Michaelson, K. L. & contributors. (1988).  Childbirth 
   in America.  Massachusetts: Garvey Publishers, Inc.

Mitford, J. (1992).  The American way of birth.  
   Middlesex, England: Penguin Books.

Randall, C. (1991).  Why Midwifery Now.  Published by 
   The Tennessee Midwives Assoc.

Rooks, J. P., Weatherly, N. L., Ernst, E. K.,  
   Stapleton, S., Rosen, D., and Rosenfield, A.   
   (1989).  Outcomes of care in birth centers: The
   national birth center study.  The New England
   Journal of Medicine.  321(26), 1804-1811.

Tew, M. (1990).  Safer childbirth?  A critical history
   of maternity care.  New York: The Free Press.

Wagner, M. (1994).  Pursuing the birth machine: The 
   search for appropriate birth technology. 
   Australia: Australian Print Group.

Wertz, R. W. & Wertz, D. C. (1977).  Lying-In: A 
   history of childbirth in America.  New York: The
   Free Press.

Women's Institute for Childbearing Policy, National
   Women's Health Network, National Black Women's 
   Health Project & Boston Women's Health Book 
   Collective (1990 & 1994).  Childbearing policy
   within a national health program: An evolving 
   consensus for new directions.  Boston,
   Mass.: Women's Institute for Childbearing Policy.

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