Not just money

A recent article by Jennifer Block, author of the book Pushed which takes a close look at C-sections in America, highlights the disparity between what we as a country spend on maternity health care and what we receive, based on outcomes like maternal and neonatal morbidity and mortality and the premature birth rate. With a price tag of $86,000,000,000 in the year 2006, for an average cost of about $21,000 per birth, we should be getting better results than we are. I understand that a lot of that money goes to help babies who are born too early, and I don’t begrudge the amount it takes to save a life; however, I do wonder why we have so many babies being born too early. Why do we have such dismal results, when we spend so much? — according to the article, we spend twice per capita of what other countries spend, but we are far behind them when it comes to results.

The answer, according to Ms. Block, is to increase the number of midwives, both in and out of hospitals. She notes that 100 midwives saved the state of Washington an estimated $2.7 million over the course of two years; which also reminds me of this midwife I’d previously read about, who works in Washington, D.C., and keeps her funding by noting how much money they have actually saved by going low-cost and low-tech, while getting results that are twice as good as average.

Part of the reason for the midwives’ good results is the much lower use of C-sections, which are expensive, especially when compared to out-of-hospital vaginal birth (mine cost about $3000 apiece for all prenatal care and everything). When a midwife attends a home birth, all the care is included in a single fee, rather than billing for the monitoring of the baby, the after-baby care, the postpartum checkups, etc. One thing that surprises me about getting a bill from the hospital is that often that’s not all there is to it — there’s one from the doctor, the anesthesiologist, and the hospital, and possibly extras for other services rendered, depending on the circumstances.

But hospitals are reluctant to use midwives. Some hospital-based midwives are not allowed to attend out-of-hospital births lest they lose their privileges at the hospital. Despite the fact that you get more for less with midwives, and especially so in an out-of-hospital scenario. But, insurance companies don’t pay for a midwife to “labor-sit” — it’s not “billable” like the use of technology. So it would cost hospitals more to have one-on-one care with laboring women (which they can’t bill, but which shows much better outcomes for mother and baby), than it is to hook the women up to ten kinds of machines (which are billable, despite some questions about their actual efficacy in reducing negative outcomes for mother and/or baby).