At a time when maternal mortality rates are decreasing worldwide, they more than doubled between 2000 and 2014 in the U.S. and particularly affected women of color. A simple solution to the skyrocketing costs and scarce access to maternal care is at our fingertips: nurses. Jessica Henman got her master’s and license as a certified nurse midwife in 2010, but when she went to practice in the St. Louis area, she hit a wall. She needed to establish a legal “collaborative agreement” with a doctor who would review her charts, approve prescriptions, and be held liable for her work. But because Missouri doctors are limited in the number of advanced practice nurses they can collaborate with (three), she had a hard time finding one. “I contacted over 100 physicians and couldn’t find a collaborator,” recounts Henman. In Missouri, a doctor needs to review the work of advanced practice nurses; if that doctor gets hit by a bus and isn’t able to practice, Henman can’t practice. Ironically, Henman went back to get a lesser degree as a certified professional midwife so she could practice without a collaboration agreement. For her first two years as a midwife, Henman operated under a lesser certification and only took low-risk pregnancies of mothers able to pay out of pocket.
To do what they’re highly trained and licensed to do—such as take blood pressure, carry out maternal health checks, and, in the case of certified nurse midwives, deliver babies—nurses across the country face different rules about what parts of that training and licensing they’re able to put into practice, and these regulations are encouraged by the American Medical Association, which claims it protects patient safety. A new study in the Journal of Health Economics examines the effect these additional regulations, or scope of practice laws, have on maternal health outcomes. The answer: none. Being supervised by a doctor doesn’t improve maternal health care, but it certainly makes it more costly and difficult to get.
The study’s lead author, Sara Markowitz, says the study shows that “Barriers aren’t related to care—they’re administrative red tape. The arguments that doctors are making—[that they are being] protective of women and infant health—are not bearing out.” In other words, states that make it more difficult for nurse midwives to practice don’t experience better maternal health. They do, however, see higher rates of cesarean sections and induced labor. Markowitz attributes this difference to competition from midwives—doctors change their behavior depending on the behavior (and perhaps power?) of nurse midwives. When nurse midwives can practice, doctors are less likely to recommend high-risk treatments unless they are very necessary.
Markowitz et al.’s study provides evidence that the choice between using nursing or OB-GYN care does not affect many outcomes, such as birth weight and gestational age. That’s because most of the important care pregnant women need—advice to monitor stress, take prenatal vitamins, and avoid smoking and drinking—could be given by a midwife or OB-GYN.
If these providers are available and their care adequate, why are so many women having trouble accessing family planning, care at each stage of their pregnancies, and support after delivery? Even if midwives work through the red tape to be able to practice, many patients who need them can’t afford them. According to Mary Jane Lewitt, CNM and a co-author of the study, there are many patients caught in the middle who “make too much for Medicaid and not enough for private insurance. They can’t afford prenatal care and drop into emergency labor and delivery.” And when labor and delivery units close and the number of obstetricians declines, as they have in rural America and across the broader U.S., child and maternal health suffers. A new study by Peiyin Hung et al. found that, between 2004 and 2014*, 2.4 million women lived in counties with no obstetric services: 9 percent of rural counties saw all obstetric services close, and another 45 percent did not offer obstetric services to begin with. Even in D.C., as of October, there were no obstetric facilities in the eastern half of the city.
Rita Ledbetter, a CNM at Medical Arts Associates in Moline, Illinois, has also struggled with collaborative agreements across her 24 years: “For me, we’re at the mercy of our collaborative physician.” Even if a CNM establishes a collaborative agreement, paying for labor and delivery may still be an issue. Reimbursement rates from Medicaid are low, and payments are often made late. Ledbetter says that when reimbursement rates for maternal health care decreased in 2015, her practice, which she describes as “two-thirds indigent, one-third yuppie,” decided not to take those low-income clients any longer. “There was a whole cohort of women without care. For me, what that meant, I refused to stop seeing very high-risk patients. I was truly worried that I could get fired, because ethically I could not do what my place of business was requiring. They [Medical Arts] worried about running a business. I was worried about dumping patients,” says Ledbetter. And “dumping patients” meant moms and babies would probably go without care.
Kristin Richman, a California-based CNM, also struggles with reimbursement rates: “Medicaid doesn’t cover out-of-hospital midwives [in California], and midwives have difficulty opening private practices due to onerous regulations.” Medicaid and the Children’s Health Insurance Program pay for nearly half of all births in the U.S., excluding many individuals from using practitioners like Richman in a state that needs them the most. California anticipates a primary care shortage by 2030.
But it doesn’t have to be that way. Mairi Breen Rothman has been in practice along the Washington-Maryland border since 1996. Because Maryland’s laws were much more burdensome than the district’s, when she opened her own practice—M.A.M.A.S. Inc.—in 2007, she started in D.C. Thanks to the efforts of nurses like Rothman, in 2014, Maryland began allowing certified nurse midwives to practice with just evidence of their education and a license. The result? “We’ve attended over 600 babies, have a 5½ percent cesarean rate, and an 8 percent transfer rate.” Translation: lots of healthy babies born with less expensive, less risky procedures.
Rothman contends that if she or other CNMs were able to take patients covered by Medicaid, they could help reduce the risk and cost of maternity care by providing the services they do—like important ongoing health monitoring—instead of the ones hospitals opt for, like costly C-sections. “We would like to offer our services to women on Medicaid, but Medicaid currently requires a prohibitive amount of liability insurance that we really don’t need since we are not part of an institution. If we were able to serve Medicaid clients, we estimate that we would be able to save the state of Maryland quite a bit of money.”
If midwives had the ability to work to the full extent of their training, their practice would expand access, reduce cost to maternal health care, and provide meaningful job opportunities in the fastest-growing sector of the economy, care work. But making those changes won’t be easy, largely because the status quo is maintained by powerful organizations like the American Medical Association. Though the gender breakdowns of the professions have changed, the elevation of historically masculine jobs like doctors and a devaluation of feminine jobs such as nursing may still be swaying policy toward barriers that are actively hurting care. Polls show that nurses are the most trusted of any profession. Perhaps it’s time for policymakers to translate that respect into higher wages and independence.
*Correction Nov. 6, 2017: This post originally misstated that Peiyin Hung’s study on access to obstetric services covered results found between 2000 and 2014. It was from between 2004 and 2014.
