Peggy Garland, a certified nurse-midwife and Coordinator of the Massachusetts Coalition for Midwifery, says the state acts against the interests of women and mothers by limiting access to midwifery services:
Did you know that almost a quarter of all hospital discharges involves maternity care (mother and newborn)? That six out of fifteen of the most common hospital procedures involve maternity care? That Cesarean section is the most commonly performed surgery? Why are so many procedures being performed on essentially healthy people? It’s the same reason behind sky-rocketing costs in all other sectors of health care: reimbursement is procedure-driven.
None of us would want to stint on the health of mothers and babies if all these procedures produced improved outcomes. But our outcomes are among the worst in the developed world and are not improving. The long-term health problems for women associated with Cesarean section are only now being understood. Maternal mortality is actually increasing. Some of the problem is undoubtedly due to excess interventions, especially those of unproven effectiveness.
The hallmark of midwifery is care with minimal interventions, with a focus on those that are evidence-based. Numerous studies of midwifery care involving low-risk women show lower costs and equal or better outcomes, as summarized here, in a report by the prestigious Milbank Memorial Fund.
In 2006, in Massachusetts there were 26,141 Cesarean sections (out of 77,670 births.) If we could reduce this surgery by 1% we would experience a cost savings of nearly $1.5 million. Boston itself provides a good example of the magnitude of the potential cost savings: the three Boston hospitals with the most midwife-attended births saved the Commonwealth nearly $3 million in Medicaid reimbursements in 2006 by reducing Cesarean sections, compared to the Boston hospitals that had few midwives. (1)
We could also allow low-risk women on Medicaid to choose out-of-hospital birth. States that have made state-licensed midwife services available to women on Medicaid have been glad they did. According to Jeffery Thompson, MD MPH, Chief Medical Officer, Washington State Department of Social and Health Services:
In 2007, the Washington State legislature commissioned a cost-benefit analysis from the Department of Health on licensed midwifery care. This independently-conducted analysis found that licensed midwives directly save the State of Washington at least $473,000 per biennium in cost-offsets to Medicaid when women give birth at home or in free-standing birth centers. It should be noted that this was a very conservative estimate which reflects only avoided costs associated with licensed midwives’ lower Cesarean section rates. When facility fees and costly medical procedures such as epidurals and continuous electronic fetal monitoring are factored into the equation, the actual savings to Medicaid biennially are approximately $3.1 million. These savings occur with licensed midwives attending just under 2% of the births in the state. (2)
Massachusetts midwives have encountered regulatory barriers that limit their availability to women. Only 60% of hospitals with obstetrical services in Massachusetts have midwives. Many of those that do have midwives have not expanded their services because they aren’t aware of the cost savings they are getting—ironically, current law causes midwives to be invisible in hospital accounting systems. Massachusetts does not regulate midwives providing homebirth services, as Washington State does (and NH and VT), therefore denying women on Medicaid a quality low-cost option.
Senator Richard Moore, Chair of the Health Care Finance Committee, recognized some of these issues several years ago when he introduced legislation to streamline and consolidate the regulation of midwives in the Commonwealth. As we move from the provision of universal coverage to the painful task of cost-savings, we can use some simple ways to lower costs, increase satisfaction and improve outcomes for our families. Increasing access to midwives (for women who want them) has just such potential.
 MA DPH, secondary analysis Kelly Roberts, RN, CNM
 From letter of support submitted to the Congressional Budget Office July 2009.