Health Care Reform Begins at Birth

By Christine Cupaiuolo — December 29, 2008

“If the United States is serious about health reform, we need to begin, well, at the beginning,” writes Jennifer Block in this L.A. Times op-ed that argues the United States health care system could save billions by overhauling the American way of birth.

Block, the author of “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” continues:

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. […]

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%. Imagine if hospitals started promoting best practices: giving women one-on-one, continuous support, promoting movement and water immersion for pain relief, and reducing the use of labor stimulants and labor induction. The C-section rate would plummet, as would related infections, hemorrhages, neonatal intensive care admissions and deaths. And the country could save some serious cash. The joint Milbank report conservatively estimates savings of $2.5 billion a year if the caesarean rate were brought down to 15%.

To be frank, the U.S. maternity care system needs to be turned upside down. Midwives should be caring for the majority of pregnant women, and physicians should continue to handle high-risk cases, complications and emergencies. This is the division of labor, so to speak, that you find in the countries that spend less but get more.


  • “Midwives say the same economic forces that have led consumers to stay home instead of shopping is hitting the birthing business, albeit on a small scale,” reports the Salt Lake Tribune. A sidebar piece notes that although Utah has the the nation’s highest fertility rate, there are just two licensed birth centers in the state. Midwives are trying to open more.

5 responses to “Health Care Reform Begins at Birth”

  1. Thanks for the link love!

    I also heart the book “Pushed.” I will definitely be using its well researched and extensive references section when I write the grant for my research project.

  2. I hope that Jennifer Block, on target as usual in the LA Times, will comment on The National Children’s Health Study, as mentioned in both Newsweek (Dec 15) and the NY Times (Oct.27). It’s a big, expensive push to track the health of our nation’s kids from birth to adulthood, looking at the incidence and causes of asthma, obesity and other burgeoning health problems through the lens of all kinds of post-birth influences (like toxins in the environment…see articles.) While it’s really fine to devise a study to improve the health of American kids, sadly, the study will overlook the one vital area that most impacts the immediate health of every baby, and has life-long consequences: HOW each baby is born. Because birth in this country is a thoroughly managed and medicalized event, the normal progression of labor and birth for most women and their babies, no longer exists. There is a wealth of “gold-standard” research showing that many of today’s obstetrical practices, (which vary from hospital to hospital, and caregiver to caregiver, by the way), are not based on the best science, and are harmful…to babies. Some of the areas of ill-health in children that the study will address can be attributed to the very circumstances of birth… asthma and low birthweight for instance, steadily on the increase. OB’s now induce labor before 39 weeks for many reasons, some of which do not hold up to scrutiny (good studies for this). Even if a woman is artificially inseminated and knows her “exact” due date, the gestational age of her baby, the baby’s actual maturity, cannot be reliably predicted (more good studies) even by ultrasound, so we now have lots babies called “near-termers” (a new birth category), who may be only days short of being ready to survive without problems, but who are nevertheless induced to be born, and often have to do a stay in the NICU because of lung immaturity or low birth weight born too soon. These babies can be at greater risk for asthma, because chemical induction of labor doesn’t allow the baby to get certain hormones from the mother which prepare the lungs for breathing. Same for c-section babies who don’t get any labor. There are many good studies that link cesarean section to asthma, and rates for both induction and c-section are rising precipitously. There are studies that show that even inductions and c-sections that are done for “medical” reasons for the health of mother or baby, are done most often Monday-Friday, 9-5. Isn’t it amazing then, that those mothers happened to need medical intervention just when it’s most convenient for their OB’s? Do we think that perhaps labor is managed to suit the schedules of caregivers? The Wall Street Journal, in a recentt Health Journal column sports the headline “New Science Suggests Risks of Scheduling Births Early”..ya think? Another practice harmful to babies is immediate clamping and cutting of the umbilical cord. Fifty-to-sixty per cent of a baby’s blood is still in the placenta immediately after birth, with stores of iron and other important stuff that the baby needs for success in its first months of life and thereafter, but just ask, and women will tell you that “it all happened in a rush“, the cord clamped and cut within seconds of birth. A few minutes of patience, and the baby will actually “clamp” its own cord, when its body has the right amount of blood for profusing lungs and brain for life outside in the world. Will the study address this? And then there’s diabetes and obesity… Human milk is the only food that human babies need for the first six months of life, and breastfed babies just don’t get diabetes in anywhere near the same numbers that formula-fed babies do, and their rate of obesity in childhood is way lower, but the drugs routinely given to mothers in labor have a negative impact on a baby’s normal and natural abilities to feed. Many mothers, especially first-timers, heartbrokenly give up, because it can take as long as three or four weeks for their babies to recover fully from the effects of fentanyl, a drug given in every epidural. Even the amount of that drug varies from one anesthesiologist to another. Who is giving the “best” amount and for how long? There’s no way to know, and the studies (yes, good ones) on the negative impact of fentanyl on breastfeeding neonates are compelling. Has depriving babies of the birth hormones that bathe their developing brains during labor led to increased incidence of ADD and ADHD, or contributed to autism where there is a predisposition? There are practices that are harmful to the mother (look ‘em up) like routine episiotomy, back-lying (hurts baby too by depriving both of oxygen) and routine IV, which fills the baby up with water, just as it does the mother, and yet the studies that refute those practices are too often ignored if it means changing one’s ways. These studies have been accumulating for thirty years. (See the Cochrane Library Database.) Let birth proceed more normally, interfere way less, and study the impact of THAT on the health of babies, along with whatever else you think is important, but without ever evaluating the results of current birth practices, and using normal birth as the physiological standard, the National Children’s Study cannot truly evaluate the factors that impact the health of our babies.

  3. Jackie,

    Great post! I found your points about the impact of birth on a babies well being interesting and well said. I myself am an RN in a hospital and had my baby last year in a birth center. Despite all of the research out there to show the safety of having a baby in a birth center, I met significant resistance from the nurses and doctors that I work with. You would think that medical professionals would be the first to understand current research but instead, of the three other healthy early 30’s women pregnant at the same time as me; the RN was induced and then had a c-section at 40 weeks, baby was small… the PA had a c-section, labor was taking too long… and the Doctor had a scheduled c-section no trial of labor because she wanted to. I was startled by these outcomes and while each baby is doing well, one didn’t nurse and another weaned after only a few months. I too hope that research will look more closely at the health of babies starting with prenatal choices made by women including appropriate weight gain and environmental exposures all the way through birth and the factors influencing children health throughout their entire life.

  4. Emily,

    I, too, am an L&D/Mother –Baby RN. I now teach, and am extremely happy to hear you saying what you are saying. Yet, the other health professionals are doing what you might expect, non-health professionals to do; making choices regarding their health care with what appears to be no regard to cost or even worse, to their specific knowledge/training. You also mentioned about more research being necessary relating to prenatal choices and babies health. I concur. And you would be as good as any to complete this research. Many RN’s are conducting hospital research in an area of interest that would speak to health concerns appropriate to their departments. Actually, I think you would be perfect for the task! The information gathered would add weight to what appears to definitely be essential for informing every women about what they should be made aware of regarding their personal childbearing health.

    DReed RN

  5. I am an L&D nurse (have been for a long time) and a graduate student. I must say, I don’t agree with your stance. You say that c-sections, hemorrhages and infections would plummet if midwives labored the majority of patients? I think the opposite to be true, why do you think maternal and infant morbidity and mortality have dramatically decreased over the years? It is not because we are all delivering our babies “all natural,” it is because of the medical advances we have made to this field. I’ve had patient’s whose babies have died because of them wanting a natural birth so bad. One young lady pushed for four hours (at home), the head came out and got stuck. Her baby died before the EMTs even got there. I think to push “all natural” and deny that medical advances have helped moms and babies is crazy. I’m sorry, but I see absolutely nothing wrong with a woman wanting an epidural to help with the pain. Epidurals have been used for many, many years and are very effective in pain relief and have no side effect to the baby. I have labored women with and without epidurals, and the ones with epidurals are so much happier and enjoy the experience a lot more. I’m not saying that I am not supportive of a patient who does not want interventions, but to a point the patient needs to be educated. If a patient comes in and refuses an IV or fetal monitoring, why did they come to the hospital in the first place? I think education is the key. Too many women are concerned about how the baby gets here. I don’t understand that. Let’s focus on getting your baby here healthy.

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