Show Me Institute editor Eric Dixon argues in this commentary that, although a circuit court judge recently struck down a controversial midwifery provision inserted by Sen. John Loudon from a health insurance reform law, the measure deserves to be resurrected.
By Eric D. Dixon
Ever since HB 818, the ground breaking consumer-based health insurance reform bill, passed both houses of the Legislature by wide bipartisan margins in May, news reports have focused on a small provision legalizing midwifery in Missouri. This is understandable — it was inserted at the last minute using a word, “tocology,” that most legislators wouldn’t understand or research before voting. The provision spurred dissent from several quarters — legislators complaining that they’d been duped, constituents complaining that legislators didn’t bother to understand the legislation they voted for, and doctors complaining that the midwife provision would reduce the safety of childbirth in Missouri. Although a circuit court judge recently struck down the provision, after the Missouri State Medical Association challenged its legality under the state constitution’s single subject requirement, advocates for midwifery say they plan to appeal.It’s easy to understand why the midwife provision overshadowed the rest of the insurance bill; it’s a juicy story of political controversy and legislative dysfunction. But what about the actual effects of the provision? Would legalizing the practice of midwifery without the presence of a doctor reduce the quality of childbirth? The evidence suggests otherwise.
In 1998, the National Center for Health Statistics and the Centers for Disease Control released a study finding that “the risk of experiencing an infant death was 19 percent lower for births attended by certified nurse midwives than for births attended by physicians. The risk of neonatal mortality (an infant death occurring in the first 28 days of life) was 33 percent lower, and the risk of delivering a low birthweight infant was 31 percent lower.”
One contributing factor to these statistics may be that midwives generally will not accept high-risk patients — sending them to normal doctors instead. Pregnant women who are extremely overweight or diabetic, drug users, those who have a history of hemorrhaging, or who have previously had a cesarean section, are all likely to be rejected by a midwife. This means that childbirth statistics for doctors might beless favorable simply because they’re treating a higher proportion of risky patients — but it also means that midwives tend to avoid foreseeable complications, which makes their services much safer than detractors might have you believe.
Midwifery advocates often point out that childbirth, in and of itself, is not a medical event — although it can become one. As skydivers and mountain climbers know, adults can legally engage in any number of risky activities without the presence of a doctor. Although these activities can escalate into medical emergencies, most do not. The midwife provision in HB 818 would have ensured that midwives who are legally allowed to practice will be those with the training to mitigate risk, and who can recognize when medical intervention is necessary.
Expectant mothers are capable of weighing their childbirth options without the aid of state law, and each one of those options carries its own risks. Giving birth in a hospital exposes both mother and child to infectious diseases that they wouldn’t encounter at home — and hospitals generally do not disclose their infection rates. In 2002, the Chicago Tribune reported that “Deaths linked to hospital germs represent the fourth leading cause of mortality among Americans, behind heart disease, cancer and strokes,
according to the federal Centers for Disease Control and Prevention. These infections kill more people each year than car accidents, fires and drowning combined.” Access to medical technology during childbirth may be worth the risk of infection, but that’s a judgment call best left to expectant parents.
One fact that’s often overlooked in the debate about the safety of midwifery is that it’s already legal for just about anybody to deliver a baby in Missouri. You can have your neighbor or your mail carrier or your pizza guy deliver your baby without legal repercussion. It’s only when you seek out someone with relevant experience and pay her to perform a delivery that it becomes against the law. Any system that penalizes training and competency just because money is involved needs to be altered.
Hopefully, this provision will be resurrected — either on appeal, or through a less controversial legislative action. It’s important that consumers be allowed autonomy not only in choosing insurance policies, but also in choosing what type of care they want to receive.
Eric D. Dixon is the editor for the Show-Me Institute, a Missouri based think tank.
12 responses so far ↓
1 Jessica Kerr // Aug 10, 2007 at 1:18 pm
What a rational analysis! Thank you. This is exactly what is infuriating about the medical associations trying to impede legalization of midwifery: we are capable of making good decisions about our own health care. We want to be allowed to choose our safest option without exposing a trained midwife to prosecution.
Clear legislation has been introduced and will be introduced again to legalize and regulate certified professional midwives. A majority of both houses wanted to vote for it last session! Hopefully next year it will get past the filibustering opposition of the doctors’ trade unions.
2 Jim Byrne // Aug 10, 2007 at 5:35 pm
It is my strong belief that Judge Joyce willfully violated the Missouri Constitution by entering her ruling. She chose to exercise power that was not expressly provided her by the Missouri Constitution. She has evidently let the allure of power cloud her judgment.
The foundation of our legal system is in need of repair. Much like building a house on a faulty foundation, the creation of new laws are destined to failure unless the foundation is adequately repaired.
Jim Byrne
3 Ida // Aug 10, 2007 at 9:23 pm
Thanks for a great editorial full of clear thinking.
4 Tina // Aug 12, 2007 at 6:23 am
This is one of the most logically thought out editorials I’ve read about midwifery from a group which doesn’t hold midwifery as one of its main issues.
I’d add that there are several other disadvantages of hospital birth including the high rate of unnecessary cesarean sections (major abdominal surgery).
I, too, believe parents are more than capable of making the appropriate decision (for them and their baby) about where and with what support their baby will be born. I don’t understand how a parent would care less for their baby than a legislator or judge, but that’s what’s being told to Missouri parents.
5 Elizabeth Allemann, MD // Aug 12, 2007 at 7:14 am
Thank you for a careful and thoughtful analysis of an issue that is more controversial than it needs to be. Just to be clear, in all the good studies comparing the safety of midwifery care to that of physician care, only healthy women are considered. The argument that, in these studies, doctors look bad because they take care of sick women, is false. Only the outcomes from women who would have been accepted for care by a midwife are counted. Of course, since these studies are not randomized and women choose their care providers, maybe some women have an intuition that they need physician care and so are in the hospital care group. That said, the science is clearly on the side of increasing access to midwifery services and home birth care, if we want healthier mothers and babies. I think we like to believe that all of the discomfort and expense of receiving birth care in a hospital is good for mothers and babies, but that idea just isn’t supported by the science. Every woman who wants a home birth deserves to know that this can be a responsible choice. The state has no legitimate interest in discouraging, much less criminalizing, her access to a well-trained, highly skilled midwife.
6 Jill Mc // Aug 12, 2007 at 9:01 am
What a clear statement of the issue! Thank you.
I find it hard to swallow when the medical professionals advocate “taking control of your own health” such as knowing what medicines you take. The medical community is all for patient involvement when it reduces the doctors’ liability. When it comes to midwifery, though, they expect us to take their word for it when power and profit are at stake, not public safety.
I care more about my unborn child than all the legislators and judges in the state combined. I am qualified and educated to make a choice where I wish to birth that child. I don’t want a hospital birth and all the risks that come with it just because doctors say “Because I’m the doctor, that’s why.”
7 Lydia Cardoza // Aug 12, 2007 at 9:40 pm
Thank you for writing this article and for the research that went with it.
As a mother of two homebirthed children and a third on the way, I am a huge fan of Midwifery!
8 Jennifer Steinberg // Aug 12, 2007 at 9:58 pm
Thank you so much for writing this article. I am a mother of seven children (none of them home-birthed) who thinks that I am more than capable of deciding where to have my child. The reasoning that legislators who know nothing of my health think they can know more about what is best for my unborn child is totally absurd!
Secondly, I am so tired of hearing them cry “foul play” when they didn’t even bother to read the wording of the bill they were passing… does this bother anyone else but me?? Are these the type of elected officials we want running our state? I think anyone who representing any person in Missouri ought to at the very least read what they are actually voting on.
Lastly, I cannot believe in this day and age mothers in the state of Missouri can CHOOSE to kill their own child, but we can’t CHOOSE to have that precious gift in our own home. How sad our nation has become.
9 Ata Siddiqui, MD // Aug 13, 2007 at 7:56 pm
The issue is not the personal choice. People can do whatever they want. The issue is whether it is OK for less educated and lot less qualified people to try to practice GYNECOLOGY and OBSTETRICS? My answer and the Missouri court’ answer is “NO”.
Taking care of pregnant mothers and babies is practice of medicine and has been for past couple of centuries. Propnents of allowing midwives to practice independently want to take us back in stone age.
When it comes to taking care of simple stuff such as auto, plumbing, carpentary, etc. we consult a qualified licensed person to do the job. Why would someone want a non qualified person to take care of their loved ones. If something goes wrong who are you going to blame? Midwifes would not have any liability since their scope of practice is very limited and you knowingly let them take care of mom and baby. You can not bring them to justice. No laws rules or regulations for them.
You would run to nearby Emergency Room where a qulified team of professionals headed by a PHYSICIAN is going to rescue!
It takes physicians years of education, college, medical school and then speciality specific extensive training to be able to practice GYNECOLOGY and OBSTETRICS (medicine of mother and baby). Does any body really believe that midwives with their limited knowledge and training should be able to take care of mothers and the precious new comers. A non qulified person who has no oversight or accountability. I don’t think so.
This is exactly what proponents of midwives are asking!!
10 Jackson // Aug 13, 2007 at 8:55 pm
Dr. Siddiqui,
I hope you practice medicine better than you read newspapers. The judge does not agree with you. The court said the midwifery issue was inappropriately added to HB818. I think when the issue is taken up in the SC they just may decide that insurance paying for midwifery services made legal in the bill may actully fit a bill dealing with “Health Insurance”.
I hope that is the case since Doctors have not provided any factual evidence that support their contention that doctors are any better at normal delivery than midwives. In fact, I would go so far to say they were not as good since they can’t compete with the personal attention the midwives give before, during and after the birth.
11 Shannelle // Sep 10, 2007 at 8:38 am
Thanks for writing this beacause i want to have a home birth but am unable because I live in Missouri and can not have a midwife. I am stuck between a rock and a hard place.
12 Ronda // Sep 11, 2007 at 4:44 am
Siddiqui,
The word “doctor” means teacher. My midwife taught me more than any of all the doctors combined in a lifetime did (in regards to childbirth). As far a taking us back to the “stone age” perhaps we need to go back and take a good look. In fact, let’s look at Holland and Europe. The practice of midwifery has existed as long as birth became known and the outcomes far outrank that of the United States. So Dr. Siddique, please do what you do best and handle the high risk prenancies and let our midwives do what they know best. I think you’ll find that doctors and midwives can work nicely together. Some docs have already figured this out.
Leave a Comment