A variety of regulations on midwives has caused maternity costs to soar and threatens the care of women and children, states a new report.
The cost of home birth by a midwife averages $4,000, while hospital-based births cost an average of $13,000, states “Midwifery Licensing: Medicalization of Birth and Special Interests,” a working paper by Steven Horwitz and Lauren Hall published by the Mercatus Center at George Mason University on November 16.
“Midwives face a tangle of regulations that interact in unpredictable ways,” said Hall, who completed the study after Horwitz’s death, to Health Care News.
Midwives ‘Providing Uncompensated Care’
Licensing restrictions increase costs by requiring highly trained physicians to attend births when there are no complications to a pregnancy, states the study.
Reimbursement for midwives under Medicaid and private health insurers is lower than for other medical professionals, states the study. This discourages the coordination of care needed to assure the health of both women and infants, states the report.
“Lower reimbursement rates are often justified on the basis that most midwives have fewer years of education than physicians, but midwifery care is also more time-inclusive than the medical model, meaning that many midwives end up providing uncompensated care,” write Horwitz and Hall.
Regulations Create ‘Maternity Deserts’
In addition to licensing, some states require supervision of a midwife’s practice by a physician, and a relationship with a hospital or clinic, says Hall.
“Licensing affects your ability to bill Medicaid, and Medicaid reimbursements for midwives are in turn artificially low,” said Hall. “Add to that the regulations in some states that require agreements with hostile parties like hospitals and physicians or certificate-of-need laws that require midwives to put up hundreds of thousands of dollars to begin practicing (or that allow hospitals to veto midwifery care altogether) and you create an environment in which the benefits of providing high-quality maternity care simply don’t outweigh the costs.
“We see this dynamic at play in maternity deserts all over the United States. as well as a catastrophic dearth of providers for communities of color who are the most at risk for severe maternal morbidity and mortality,” said Hall.
Restrictive Licensing’s Legacy
Medical trade groups have tried to restrict the practice of midwifery, which has been a tradition among African Americans dating back to the 17th century, and continues to be advocated by organizations such as the National Black Midwives Alliance, says Hall.
“Our study demonstrates that we have a long history of regulating health care for the benefit of special interests, starting with the original restrictive licensing of midwifery in the early 1900s that all but eliminated the tradition of ‘grand’ Black midwifery,” said Hall.
“That legacy (of restriction) continues today, as hospitals lobby against bills facilitating birth centers and home birth midwifery, even when we have ample data that these options, when appropriately regulated, are as safe as hospitals and even sometimes produce better outcomes than hospitals for mothers and infants,” said Hall.
Money, Not Science
“A lot of people think the regulations are following the science, but they’re not,” said Hall. “They’re following the money, and the money is in big, consolidated hospital complexes that employ a lot of people and hold incredible political sway.”
Michigan, for example, increased fees and licensing requirements for midwives in 2019, creating a new occupational licensing category for “certified professional midwives (CPM),” Heartland Daily News reported on August 20, 2019. CPMs must pay an application fee and a one-year licensing fee of $650 plus $400 renewal fee every two years, must complete an educational program accredited by the Midwifery Education and Accreditation Council or another organization approved by the state, and complete at least 30 hours of continuing education every two years.
Continuing education must include one hour in pain and symptom management and two hours in cultural awareness. Midwives must also complete training on identifying human trafficking and undergo a criminal background check.
‘More Direct Care’ Needed
Maternity care is part of a larger battle, says Matt Dean, a senior fellow for health policy at The Heartland Institute, which co-publishes Health Care News, and retired state legislator who served as Majority Leader and Chairman of the Health and Human Services Finance Committee in the Minnesota House of Representatives.
“When scope-of-practice battles erupt, it’s often a smaller skirmish in a larger turf war over money, patients, and safety,” said Dean. “Things work best for the patient when professionals work ‘at the top’ of their license. That basically means that more expensive professionals, fewer in number, should focus on more complex patients, while uncomplicated cases should be handled with less expensive, more direct care.”
The Covid-19 crisis is a potential boon to less restrictive maternal care, says Dean.
“Hospitals, states, and providers have had to work together to try things that they would not do under normal circumstances,” said Dean. “Rethinking how care is delivered breaks down barriers and unnecessary restrictions built by generations of outdated standards of practice and special interest turf battles.”
Kevin Stone (email@example.com) writes from Arlington, Texas.
Steven Horwitz, Lauren Hall, “Midwifery Licensing: Medicalization of Birth and Special Interests,” Mercatus Center at George Mason University, November 16, 2021: