Lauren K. Hall
As COVID-19 ravages the United States, one overlooked casualty is maternity care.
While the cracks in our maternity care system were apparent even before women across the nation were forced to give birth in overwhelmed hospitals, the pandemic has shed light on the dearth of options for pregnant Americans.
Women are being separated from their partners, support persons and even their infants as hospitals struggle to contain the spread of COVID-19. Mothers like Bronx resident Amber Rose Isaac have died — not from the virus — but because overwhelmed maternity care systems couldn’t keep up during the pandemic.
These issues are not new. The United States has the worst rates in the developed world for maternal mortality, with the worst racial disparities in outcomes. Black women in New York City, for example, are as much as 12 times more likely to die during childbirth than white women.
Our maternity care system also is expensive relative to other developed countries and comes with high rates of unnecessary interventions. These problems are exacerbated by a pandemic that has strained hospital staff, reduced already ineffectual communication and increased pressure for interventions in normal low-risk birth.
These heavy costs might be worth it if we had evidence that hospitals were in fact the safest place for women to give birth. But ample research demonstrates that better access to midwifery care and out-of-hospital options like freestanding birth centers limits maternal mortality and reduces racial disparities while lowering costs.
Women’s health given low priority
Given these benefits, what is it that keeps us so far behind? Part of the problem is the fact that women’s health is simply not prioritized by the medical establishment, but a deeper explanation lies in the tangle of regulations that limit access to alternative modes of maternity care such as birth centers.
Many states, including my home state of New York, require an outdated Certificate of Need process that regulates freestanding birth centers. The CON process was created in the 1960s to reduce costs of health care by preventing destructive competition between providers, but CON laws do not work as intended.
New York has only three birth centers in a state with an average of 200,000 births per year. In Kentucky, a birth center has never made it through the certificate of need process, despite years of petitions, protests and begging.
CON laws hit birth centers particularly hard because unlike the hospital systems they compete with, the centers are small businesses or non-profits, usually run by midwives. The CON process requires upfront costs of hundreds of thousands of dollars and up to two years of meeting regulatory requirements before a birth center can open.
Even then, in many states, hospitals are given veto power over birth center applications. Unsurprisingly, hospitals don’t want more competition.
Other limiting regulations include Medicaid policies that do not cover the cost of care, forcing providers to choose between staying in business and providing services to the 50% of pregnant women who are covered by Medicaid. Other regulations include unnecessary architectural requirements such as gurney-width doors and elevators for low-risk facilities where clients are healthy and mobile. The cost of these regulations, combined with low reimbursement rates, makes the birth center model almost unviable.
Midwives face restrictions
Some states combine regulations on birth centers with a tangle of restrictions on midwives, making out-of-hospital birth all but impossible. The driver of these regulations is not public health but powerful hospital and medical association lobbyists who use the rules to strangle potential competition.
The good news is that there is an alternative. The Commission for the Accreditation of Birth Centers’ rigorous national accreditation process is grounded in medical research and is a much better fit to protect the safety of the women who birth centers serve
This model is particularly important because it provides guidelines that support safe, low-cost care that prioritizes women’s preferences and helps reduce racial disparities in care.
If more states followed the science, instead of allowing special interests to regulate health care, healthy women would not have to make heartbreaking decisions about how much risk to take by giving birth in a hospital during a pandemic.
The reality is clear: Women are being forced to give birth in overwhelmed hospitals during a pandemic in a country with high maternal mortality rates, exploding costs and terrible health disparities for people of color.
Whether as voters, public health officials, activists, scholars or expecting parents, we need to ask why low-risk pregnant Americans have so few safe options for birth.
Access to safe community-based and midwifery-led care is imperative to address the crisis of maternity care that women face. It’s time for states to allow pregnant Americans access to the low-cost high quality care that could keep them safe now and in the future.
Lauren K. Hall is an associate professor of political science at the Rochester Institute of Technology. She is author of “The Medicalization of Birth and Death.”
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