Skyrocketing insurance costs are limiting options for women in Cincinnati who want to give birth outside a hospital.
Midwives Care Inc. has had to stop conducting deliveries at private homes and at its birth center in Northside because a physician's insurer tacked on extra surcharges for his association with the midwives.
Ohio law requires nurse midwives to have a standard care agreement with a collaborating physician.
Midwifery is an ancient profession but has been met largely with skepticism in the United States, where midwives attended only 7.6 percent of births in 2002. About 99 percent of births occur in hospitals.
Profit chokes alternatives
These statistics seem to reveal a public perception that midwife-attended births aren't as safe or desirable as physician-attended births, despite many studies that indicate just the opposite. The risk of experiencing an infant death, for example, is 19 percent lower for births attended by certified nurse midwives than for births attended by physicians, according to a study by the National Center for Health Statistics.
But insurance company economics don't reflect such facts. Midwives Care had to end its standard care agreement with Dr. Warren Metherd in January because his liability carrier added unaffordable surcharges.
"The standard care agreement creates fear in physicians and hospitals that they will be held liable for our actions in a home birth or a birth center birth," says Jackie Gruer, a nurse midwife and founder of Midwives Care. "The physician associated with the process is not a bad thing, but I don't want the physician perceived to be responsible for my every action."
Midwives Care maintains a relationship with Mercy-Franciscan Hospital, but their agreement doesn't allow for births outside a hospital.
Insurance companies cite large liability payouts as the reason for rising premiums and fees, according to Deanne Williams, executive director of the American College of Nurse-Midwives in Maryland.
"What they're seeing is the frequency of awards that exceed $1 million," she says.
Much like the public misperceptions about midwifery, Williams says insurance companies are using their imaginations when they tack on extra fees for a physician's association with a midwife.
"There is absolutely no actuarial evidence that shows that there's increased risk pay-out for a physician working as the collaborating physician with a nurse-midwife," she says. "This whole surcharge thing is indefensible, as far as I am concerned."
The damage at Midwives Care has been significant. On top of restricting its assistance to hospital rooms, the practice has seen its own liability insurance increase 200 percent in the past three years. Midwives Care is now in the process of applying for nonprofit status.
"You see a for-profit basis to health care right now," Gruer says. "We consider ourselves a community-based organization, and by becoming a nonprofit organization that more reflects our belief system about our service to the community."
But the approach of Midwives Care and midwifery in general differs in many other ways from the profit system of physicians and insurance companies within which they must operate. Midwives Care views birth as a natural phenomenon, one that doesn't require physician intervention unless a problem arises.
Amy Behnke-Cupp, 31, of Northside, has had two births with Midwives Care. She delivered her first child at a hospital but opted for a birth-center delivery for her second son last year.
"Naturally having my child at the birthing center is the greatest experience I've ever had," she says.
The birth center is a former home on Hamilton Avenue, complete with hardwood floors, quilts on the walls and a bedside rocking chair. It includes two bedrooms, each with its own large bathroom.
Behnke-Cupp arrived at 1 a.m. Quiche baked in an oven downstairs while she was in labor. Her friend massaged her feet in the candlelit room. Afterwards, she took a bath in a large tub. She was at home in bed with her child and husband by 8 a.m. the next day.
"It deeply saddens me that other women won't have the same wonderful opportunity as I had," Behnke-Cupp says. "It's the best thing you can do for your baby. Midwives at Midwives Care are women who understand other women. They help women to empower themselves. It's sad that money gets in the way."
But money doesn't get in the way in every state, according to Williams. Colorado and California have passed effective tort reform, she says, to reduce the incentive for lawyers to litigate and seek large awards.
"You don't want to take financial winnings away from those who deserve them, but there is no evidence that these laws in California hurt the client," she says. "In fact, they help the client because it ensures there are providers out there."
The shrinking provider pool is of concern Midwives Care, because part of their goal is to empower women to take control of their own birthing process. Women who use Midwives Care often don't feel justified in the medical intervention they received at hospitals, Gruer says.
"I think overall our women are wanting an empowered birth, feeling like they are the ones that gave birth," says Leah Terhune, one of four certified midwife nurses at Midwives Care.
But that is an option that's diminishing across Ohio. Midwives Care sees about 200 clients a year who now face fewer birthing options.
"I'm concerned about the choices for women," Gruer says. "Do we have to send home birth back to the underground — and is that going to help women and health care in this country?"
As Midwives Care continues to struggle for its survival, Gruer says she is beginning to question whether a good health care system is compatible with capitalism.
"I'm not against capitalism," she says. "I just don't know how health care can fit into a capitalist system."
Williams is also concerned about the flaws in the current health care system.
"What happens is in any sort of system like this is the little guy goes first, and everybody can say, 'Oh well, it's just the midwives,' " she says. "I promise you, next year it will be the doctors." ©