I wrote this for you and for all the women that are raising their voices—it is my 90th birthday gift to you, some reflections on what I’ve learned in over 40 years as a nurse-midwife and advocate for birth centers.

In the United States, birth centers and hospice began at about the same time. Why did hospice care take off, eventually established in almost every community in America within three decades, while birth centers still struggle against the continuing assault on the concept of their model of care?

For almost a century, birth in America has been approached as something that needs to be cured, something that must be under medical management and control. There are hundreds of businesses and industries whose survival depends on maintaining the medical model of care for all childbearing women. Midwives and birth centers have a very different view of birth, which is that pregnancy and birth are normal physiological processes until proven otherwise.

In my view, here are the two main reasons why birth centers remain rare, yet hospice is common.

1) Follow the money: Hospice is covered by the universal health care plan Medicare, so there’s only one payer to educate and convince for national payment coverage, plus only one set of regulations for that coverage. Birth centers face a battle for multiple insurers and 50 individual state regulatory systems. Also, hospice has put together a package of furniture, supplies, and medicines they’ve determined will be needed to support the dying. I’m sure that with the volume they order, they are able to negotiate a significant savings in the purchase and distribution of these items to families and centers. Lastly, hospice relieves the family of all administrative costs by billing the single payer for their services.

2) No competition:  The care provider in a hospice setting, the nurse, is not in competition with the physician (whose work is essentially done by the time someone’s care is transferred to hospice.) The central idea of hospice is that time for curing by medical intervention is over—so the care is relegated to nurses, with support of the physician only as needed. Nurses are the appropriate providers to nurture (that is what nurse means) the patient and the family through the process of dying, with all the comfort measures available including “being with” the patient. By contrast, in the system we have today, midwives and obstetricians are in competition with one another to provide care—and get paid—for normal, healthy pregnant women.

We have allowed care for birth, one of the most important events of our lives, to become competition rather than collaboration. Midwives and physicians should be collaborating, not be at odds in their care of women—but this is almost impossible in a system that operates largely for profit. I say ‘we’ because we as women have allowed it, without even recognizing that we are paying for it through insurance premiums and taxes. As the ultimate payers in, we have to accept some responsibility for the misplaced goals in the maternity care delivery system.

Birth centers have created a visible place for midwifery to help make this happen, but it’s the cultural shift that’s lagging behind. And a cultural shift of this magnitude is never easy. However, the longer we wait, the longer we have the potential of doing harm to mothers, babies, families, and perhaps even to society as a whole. The Affordable Care Act took a major step by acknowledging the profession of midwifery and payment for the service, but it will be the rising consumer movement that moves the need for change forward. When consumers realize they are the ones paying for the services and take on the huge “middle man”  of healthcare insurers, demanding that their employers embrace the best evidenced-based care healthcare insurance available, that will be the change.

Think, for a moment, about it this way: In hospice, the person being cared for will die. Where is the long term return on this investment, on care at the end of life? It doesn’t exist! Now compare the enormous short and long-term evidence-based returns on such an investment at the beginning of life. It is not rocket science to believe that quality, compassionate care for birth can make a huge difference in our system.

What can you do? Start demanding more attention to our system of care at the beginning of life. Make your signs for the ImprovingBirth rallies say that is what you want. Make those campaigning for office start talking about it.

America moves on the dollar. Take back your voices. Develop a strong strategy to educate the middle man (insurers) to give you what you are asking for or you’ll take your business elsewhere – like Medicare. The solution has been with us for a century. We don’t need more meetings or talking or blah blah blah; we need midwives and birth centers.

Do you know that about 40 years ago that the chief obstetrician, Dr. Charles Flowers, tried to get a nurse midwifery education program established at the University of Alabama? With the support of nursing, it was squashed. Do we really have to wait another century? What will birth be like if we do?

. . .

Kitty Ernst is a midwife and visionary who has dedicated her life to improving the quality of care for moms and babies. She co-founded the AABC (American Association of Birth Centers), is a former president of the ACNM (American College of Nurse-Midwives), and serves at the Mary Breckenridge Chair of Midwifery at Frontier Nursing University.

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