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Birthing choice is both a feminist and a fiscal issue!

Birthing choice is an area of personal focus for me; I'm a strong advocate for a woman's right to birth her child where, with whom, and how she chooses. My partner's mother is a Certified Professional Midwife, having completed numerous years of schooling and apprenticeships before she could rightfully claim that title. My initial exposure to the concepts of birthing choice, midwifery, home births, and birthing centers was through conversations with her, which catalyzed my own research and advocacy into the topic. This reproductive rights issue has been at the heart of my personal feminist agenda for many years now because it's about women's ability to make choices about their own bodies, the shameful over-medicalization of women's bodies, and the devaluing of women's work.

In my home state of North Carolina, Certified Nurse-Midwives' (who train first as Registered Nurses then as midwives) are the only midwives who are legally permitted to practice, According to state legislators, the law protects the "safety" of both mother and child, despite the fact that there is no evidence that other types of midwives have worse outcomes. This means that, every day, my partner's mother has to drive roughly 45-minutes from her home in Charlotte, NC, to the birth center she runs in Fort Mill, right over the South Carolina border. If she attends home births for clients who live in South Carolina, her commute can become much longer. This sort of restriction restricts women's freedom in two ways. First, women can't legally choose to have their birth attended by a midwife other than a Certified Nurse-Midwife. Second, trained and educated midwives (the vast majority of whom are women) are restricted from being able to freely practice their chosen profession.

North Carolina's birthing laws are even more disgraceful and restrictive when a woman wants to give birth in her home, in someone else's home, or in a birth center. In North Carolina, it is illegal to give birth in a home with the aid of a midwife (even a Certified Nurse-Midwife). As you might imagine, most women aren't willing to give birth unassisted (also referred to as "freebirth"). Some are willing to take that chance, however, rather than be forced to give birth in an outside facility; sadly, there have been incidents of neonatal and maternal mortality, and increased complications, as a consequence. I'm not an advocate of unassisted birthing, but it troubles me that North Carolina's lawmakers would rather let women give birth unassisted in their homes than license and allow Certified Professional Midwives to assist with out-of-hospital births!

Midwifery and birth centers have become hot topics lately because of their potential impact on U.S. health care costs and childbirth outcomes. As an NWHN intern, I had the pleasure of attending a Congressional Briefing on this topic, and hearing representatives from the American College of Nurse-Midwives (ACNM) and the American Association of Birth Centers (AABC) discuss midwifery and birth center advocacy from fiscal and policy perspectives. The briefing explicitly advocated for increased visibility, supportive legislation, and funding for birth centers and midwives to maximize the benefits of the Patient Protection and Affordable Care Act (ACA)--commonly and lovingly referred to as "Obamacare."

The ACA seeks to secure "high-value" care for all Americans--better outcomes at lower costs--and childbirth is a key area for potential improvement. Hospitalization for pregnancy, birth, and newborn care in the U.S. totaled $97.4 billion in 2008, making pregnancy the health condition with the largest contribution to the nation's hospital bill? Yet, this huge investment isn't generating the best outcomes for women and Children: in 2010, 33 countries had lower maternal mortality rates, and 37 countries had lower neonatal mortality rates than the U.S. (3) What's with this disconnect between high levels of spending and poor maternal mortality rates? And, what's all the money being used for, since we're not getting better results?

The briefing highlighted the positive findings from the AABC's National Birth Center study II, which examined outcomes in the present maternity care environment by monitoring and recording outcomes for 15,574 women who received care in 79 midwife-led birth centers in 33 states from 2007 to 2010. (4) The study's findings indicate that the expanded use of both birth centers and nurse-midwifery services has the potential to reduce the nation's outrageous pregnancy and childbirth expenditures, and to improve women's health outcomes. In short, obstetrical care provided by a nurse-midwife at a birth center is much cheaper than care provided by a physician in a hospital.

The study clearly indicated that out-of-hospital birthing methods are just as safe as hospital births: fetal and newborn mortality rates were equally low when compared to low-risk hospital births (no maternal deaths reported; 0-47 and 0.40 fetal and newborn deaths per 1,000 births, respectively)) The study calculated that "if even 10% of the approximately 4 million U.S. births each year occurred in birth centers, the potential savings in facility service fees alone could reach $1 billion per year." (6) Much of this cost savings can be attributed to the extremely low rate of cesarean births in birth centers versus hospitals, since the former usually serve low-risk women who are unlikely to need a cesarean (which cost approximately 50 percent more than vaginal births and have higher risks). (7)

The ACA mandates that state Medicaid programs pay for services provided in birth centers. Yet, less than half of the states' Medicaid programs include birth centers as potential "Medical Homes" for childbearing women and their infants so women can gain equal access to nurse-midwifery and birth center services, if they want them. Let's not forget about the Armed Force's Service members, veterans, and their families, who also benefit from access to birth center obstetrical care. The military's insurance system, TRICARE, pays for Certified Nurse-Midwife services, but not those of Certified Professional Midwives; and, it only pays facility service fees for some birth centers. Often, TRICARE's reimbursement is inadequate to cover a birth center's costs, which deters some birth centers from accepting TRICARE clients. And, I've met several midwives who are owed outrageous sums of reimbursement money by Medicaid, but there seems to be no Federal enforcement to ensure these hard-working women get paid for their services. Clearly, Medicaid and TRICARE have some work to do.

Federal agencies need to do a better job of monitoring programs that are supposed to include birth centers as approved providers like state Medicaid programs--and incentivizing private health insurance companies--like those involved in Federal and State Health Exchanges--to include birth centers and midwives as approved providers.

In my opinion, if Americans want real health care overhaul that reduces spending and makes smarter use of tax-payer dollars, we need to embrace the high-value care provided by thousands of well-trained, highly-skilled midwives across the country. These include Certified Nurse-Midwives, Certified Professional Midwives, Direct-Entry Midwives, Certified Midwives, and Lay Midwives who practice in hospitals, birth centers, and/or personal homes. Alternative birthing choices are effective and safe, allow professionally trained midwives to work, and provide women both freedom of choice and a personalized and rewarding birthing experience. They also offer the nation a viable way to reduce our outrageous health care costs. I can't think of a reason that we shouldn't embrace birthing choice in the United States!

For more information about birthing choice, midwifery, and birth centers, visit (; the AABC (, and the Midwives Alliance of North America (

Resources and references are available on-line or by emailing

Allyson Reddy is a graduate of the University of North Carolina at Chapel Hill. She interned at NWHN in the spring of 2013 and hopes to pursue a career in the non-profit sector as a feminist health advocate in her home state of North Carolina.
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Title Annotation:young FEMINISTS
Author:Reddy, Allyson
Publication:Women's Health Activist
Geographic Code:1U5NC
Date:Jul 1, 2013
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