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Many women prefer midwives to guide them through pregnancy and birth, but increasing insurance premiums are forcing some midwives out of business. (Corbis images)

Women have fewer choices about how to deliver their babies

T he 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 Hospital and Health System, where Singer had delivered all of four 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 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 vaginal 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 her 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.

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 September 29, Full Circle Women's Health, a nonprofit midwifery practice in Tallahassee, Florida, 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.

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.

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 an average of $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.

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.

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.

"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, which means that there will be more interventions, and the more interventions, the more money you can charge." •

Labor Intensive: Working With A Midwife

By Lisa Sorg

In early 1999, when Laura Salazar Guevara's obstetrician learned she was planning to have her baby at home with the help of a midwife, he yelled at her.

"He told me, 'Your baby's going to be big and you're going to have a bad birth," Salazar Guevara said. "He said, 'How dare you have a home birth. Don't you know it's dangerous?'"

Helpful Websites

Association of Texas Midwives:

Local meetups:

Texans for Midwifery:

Texas Department of Health:
Yet, two weeks later in her bedroom, after a 16-hour labor, Salazar Guevara delivered a healthy, 8-pound, 14-ounce girl, Joaquina, with midwife Alisa Voss, and husband Jacinto Guevara by their side. She took no pain medication; nor did she have an episiotomy. "I had a perfect birth, no problems."

Although Medicaid didn't cover the cost of her midwife, (but did pay for her obstetrician) Salazar Guevara chose to pay her $40 per visit, which often lasted a half-hour, much longer than her doctor's appointments.

"The midwife took care of the physical and emotional aspects," Salazar Guevara said. "She made sure I had as good as start as possible with my baby."

The state's midwives are regulated under the Texas Midwifery Act; those who want to practice midwifery must contact the Texas Department of Health Midwifery Program and apply to be documented. Those who are already documented must re-apply each year for renewed status.

Before applying for midwife documentation, one must successfully complete a course on midwifery (either on-site or correspondence course) approved by the Texas Midwifery Board, and pass the state-approved comprehensive written exam. There are other education options and certification programs that are also valid in Texas and listed on the TDH website. Cost for the exam and documentation runs about $900.

"Alisa stressed early on how to look at pain in different ways," Salazar Guevara said. "I can see how people would be scared. You can't control your body, but it knows what its doing. Trusting in my body is what my midwife taught me to appreciate." •

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