Ever since HB 818, the groundbreaking 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 be less 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.
