When Buckminster Fuller said "call me trimtab" he was referring to the power one small part of the rudder system has to turn a great ship of state: Witness the results of a new study on midwife-led care of over 15,000 women in 79 U.S. birth centers. The end result was healthy outcomes for mothers and babies and the potential savings of more than $30 million for the U.S. healthcare system. Based on such findings, only 10 percent of the four million births each year in the U.S. took place within this model, the reduction in facility fees alone would exceed $1 billion per year. Talk about a trimtab.
Considering the mandated coverage of pregnancy care in the Affordable Care Act, the delivery of maternal child healthcare has significant potential to impact the bottom line for both state and federal agencies. Nearly half of all U.S. births are funded by federal and state government programs. Care of childbearing women and their infants in the U.S. was the number two reason for hospitalization in 2008 and is now second only to cardiac catheterization. Five of the 10 most commonly performed procedures in our institutions are childbirth related. While more than 85 percent of pregnancies are generally considered at low risk for complications, routine maternity care has become increasingly technology intensive and expensive. For example, one in three births in 2011 occurred by cesarean section. The cesarean rate rose nearly 60 percent from 1996 to 2009 without medical indications to explain the increase and cesareans are now the most common in-patient surgery in the country.
What are we getting for our investment? How savvy is our spending? While the issues are complex, a glimpse at the World Health Organization's 2010 data detailing U.S. maternity outcomes compared to other countries is sobering. The U.S. ranks 34th in maternal mortality, 38th in neonatal mortality, 66th in infants with low birth weight, and 33rd in countries with exclusive breastfeeding at six months of age.
What are needed are solutions that offer improvements in outcomes as well as reduced utilization of resources and lower costs. The study "Outcomes of Care in Birth Centers: Demonstration of a Durable Model"published in the January 2013 issue of the Journal of Midwifery and Women's Health provides a good start. The 15,574 low risk, healthy mothers in the study sought care in 79 US birth centers between 2007 and 2010. Their pregnancy, labor and postpartum care was provided by midwives. Eighty-eight percent of the mothers gave birth in the centers, while the remainder transferred to the hospital (less than 2 percent for emergent reasons). Of all the mothers in the study, 94 percent had vaginal births and 6 percent required a cesarean section. There were no maternal deaths and the fetal and newborn mortality rates were comparable to those for hospital born children in a similar low risk set of mothers.
Reimbursement for care is approximately 50 percent more for cesarean delivery than vaginal birth for both mother and baby. Given the lower costs in facility fees at birth centers as well as the lower rates of cesarean births, the births in this study may have saved more than $30 million in facility costs alone based on Medicare/Medicaid rates. This does not include other potential savings in terms of additional providers needed for surgical anesthesia and added newborn care in hospital settings.
The difference between studies that disappear into the research 'cloud', and those that can inform constructive change is knowing what needs to happen to enable their implementation. Important actions needed to make midwife-led care in birth centers more available to U.S. families include:
- Ensuring that service members, veterans and their families have equitable access to birth centers and midwives by introducing legislation to facilitate contracting with Tricare Managed Care Organizations (MCO's);
- ensuring that all federal and state health initiatives, insurance plans, Accountable Care Organizations (ACO's), MCO's, and healthcare exchanges contract with and reimburse midwives and birth centers;
- fully implementing the Birth Center Medicaid reimbursement mandate as passed in the Affordable Care Act (ACA) in 2010 (now properly implemented in fewer than half the States nearly three years after passage);
- recognizing birth centers as maternity care medical homes and developing medical home standards for them; and
- developing Medicaid demonstration projects with birth centers; especially focusing on providing access to midwife-led birth centers in at risk communities
Somewhere between the 6 percent cesarean rate achieved in this study and the current U.S. rate of 32.8 percent lies a more optimal rate which represents good health care and appropriate utilization of resources. U.S. spending on maternity care could drop by $5 billion if the cesarean rate in this country were 15 percent. While such an accomplishment is a ways off, the 'durable model' of midwife-led care in birth centers is one safe, cost-effective trimtab that could help turn the ship in that direction.