In January of this year, the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released a document that is likely to have a substantial impact on the United States maternal health care system. In the document, titled “Levels of Maternity Care,” they call for an “integrated, regionalized framework” for maternal care. This framework includes a striated classification system for levels of maternal care according to risk status. The goal of the new system is for women to receive care that is appropriate to their level of need, including moving women up to more specialized regional hospitals if they become higher-risk, thereby reducing maternal mortality and morbidity.
ACOG is a professional association of physicians specializing in obstetrics and gynecology. It has a membership of 55,000 and represents 90% of US board-certified obstetrician-gynecologists. Because the vast majority of women in the US currently seek out an OBGYN for their care during pregnancy, the standards upheld by ACOG basically set the standards for maternity care in the US. SMFM is a non-profit devoted to improving perinatal care (care around the time of birth) with a membership of about 2000.
What makes the ACOG/SMFM document really significant for out-of-hospital birth is that in their vision for the future, healthy, low-risk women are receiving care from licensed midwives and giving birth in freestanding birth centers. Until last month, ACOG had summarily written off certified professional midwives (CPM) and licensed midwives (LM) and refused to acknowledge them as part of the maternity care system. However, in the new proposed framework, birth centers comprise the lowest risk level of care, and primary care providers at this level include “certified nurse–midwives (CNMs), certified midwives, certified professional midwives, and licensed midwives who are legally recognized to practice within the jurisdiction of the birth center; family physicians; and obstetrician–gynecologists.” This is a big position change for ACOG. But why?
Many people know that the US spends more on health care than any other country in the world. However, some may be shocked to learn that more money is spent on maternity care than any other type of hospital care, and yet we rank 26th in the world in infant mortality and 60th in maternal mortality. That means that our mothers and babies fare worse than almost any other developed nation in the world. And for mothers it’s getting worse. While maternal mortality in other high resource countries improved significantly over the past decades, the maternal mortality rate in the US has increased. And that’s not even the whole problem. Women who almost died, or who suffered a complication that had a negative effect on their health increased by a whopping 75% between 2008 and 2009.
Before we go any further, I want to clarify that the absolute numbers we are talking about are still very, very small. According to the World Bank, in 2014, the US maternal mortality rate was 28 per 100,000. One of the problems is that in 1987, that number was closer to 6 per 100,000. And another problem is that even one mother dying is too many.
The reasons for these poor outcomes are complex - they are organizational, financial, cultural, economic, linguistic and technological - and we don’t have space to go into all of them here. The ACOG/SMFM framework attempts to address some parts of the problem. And that’s where midwifery comes into the equation. Midwifery care is “high-touch, low-tech” care, meaning it is very personalized, without an over-reliance on technology and testing, which can be costly. Women who receive care from a midwife also have drastically lower rates of invasive procedures like c-section or episiotomy. And guess what…midwifery care is far less expensive. Like ridiculously cheaper. In the US, the average cost of a vaginal birth is about $30,000. A c-section: $50,000. A midwife out-of-hospital? In my experience, anywhere from $2900 in Texas where the cost of living is low to $7000 in San Francisco where the cost of living is very high. So even the most expensive midwife, compared to an average hospital birth, is still less than one quarter of the price!
ACOG's position change also comes on the heels of some pretty widespread pro-midwife, pro-out-of-hospital-birth media coverage from across the pond. The UK’s National Institute for Health and Care Excellence (NICE) released guidelines on December 3, 2014 encouraging low-risk British women to have their babies with midwives. According to Professor Mark Baker, NICE’s clinical practice director: “Most women are healthy and have straightforward pregnancies and births. Over the years, evidence has emerged which shows that, for this group of women, giving birth in a midwife-led unit instead of a traditional labour ward is a safe option. Research also shows that a home birth is generally safer than hospital for pregnant women at low risk of complications who have given birth before. Where and how a woman gives birth to her baby can be hugely important to her. Although women with complicated pregnancies will still need a doctor, there is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable. Our updated guideline will encourage greater choice in these decisions and ensure the best outcomes for both mother and baby.”
This is not the first time ACOG has ceded ground to out-of-hospital birth. In 2006, ACOG released a statement insisting that the hospital “is the safest setting for labor, delivery, and the immediate postpartum period.” It concluded that ACOG “strongly opposed out-of-hospital births” and “does not support programs or individuals that advocate for or who provide out-of-hospital births.” In 2007, after quite a bit of outcry from their own membership and from consumer groups, ACOG changed their statement to acknowledge the safety of birth in out-of-hospital birth centers that meet accreditation standards. ACOG continues to oppose home birth, but does not provide any evidence for doing so.
Whatever the reason for ACOG’s most recent change of heart, this call for a more integrated, multilevel maternity care system is a positive step in the right direction. The only way to provide better care for moms and babies is if providers at all levels of care communicate and work together within a structured system. And it's obvious that women do and will continue to choose licensed midwives and out-of-hospital birth no matter what ACOG says or does. So it’s about time we all get on the same boat. I’d say we’ve got some big changes coming, and frankly, they look good.
You can read the ACOG and SMFM statement. It’s pretty easy to understand, but if it’s too much for your brain to handle today, Lamaze International does a good job of breaking it down in their research-based blog.