NY Times: "Use of Midwives, a Childbirth Phenomenon, Fades in City"

March 15, 2004 -- Today the New York Times ran a fairly balanced article by Richard Pérez-Peña that managed to convey the complexity surrounding the difficulties now confronting certified nurse-midwives, principally far higher malpractice insurance premiums and hospital- and insurance-imposed limits on their practices. The problems have reportedly resulted in slower growth in the use of nurse-midwives nationally, and an actual decrease in New York City.

The piece describes the phenomenal growth of nurse-midwifery over the last two decades, as more and more women have sought to avoid "aggressive medical techniques" used by physicians and embraced midwives' more holistic, "natural" approach, bucking the overall 20th century trend toward "treating labor and delivery as a medical experience, to be handled by doctors and hospitals." To illustrate, the story describes the experience of one Brooklyn social worker who used nurse-midwives for her births, seeking to avoid (as the piece puts it in its very first sentence) "too many machines, too many drugs, and most likely, too many men." This is obviously not an adequate explanation of the very real health benefits nurse-midwives can offer; studies have shown that they provide care that is at least as good as that provided by physicians.

Over time, the article explains, many hospitals have accommodated midwifery, opening birthing centers staffed by midwives. Certified nurse-midwife births reportedly rose from just 1% in 1976 to 7.6% in 2002 nationally, and to even higher rates in New York City. The use of nurse-midwives became popular among middle class women who "saw it as a natural extension of the women's movement." Today, most nurse-midwife births occur in hospitals. (The article rightly notes that a relatively small number of births are performed by non-nurse "lay midwives," who are generally unlicensed and who do not deliver in hospitals.)

However, the piece reports that national growth in the use of nurse-midwives has now "slowed to a crawl," and in New York City, it has actually decreased, from 12.2% of births in 1997 to 9.7% in 2002. Recently, two of the city's four free-standing nurse-midwife birthing centers closed, as malpractice premiums for nurse-midwives have exploded. One of the centers that closed said the best quote they could get for a new malpractice policy entailed a 400% premium increase; the article mentions increases of 30-75% for other nurse-midwives. Though midwives still pay far less than obstetricians--one company offered a New York area policy price comparison of $19,000 for nurse-midwives and $100,000 for obstetricians--the midwives (who are paid far less) argue that they are less able to pay the premiums.

The article discusses several possible reasons for the recent changes. One insurance executive pointed to claims related to "neurologically impaired babies" as driving up midwife premiums. Insurers are also reportedly leery of birthing centers and home births (though those are apparently declining), arguing that they are too risky, though some midwives dispute that. Midwives also cite accepted studies showing that their care is as good as that of obstetricians for low-risk pregnancies in similar settings--a fact reported deep in the story that is unlikely to have the same impact as the rationale of the social worker in the article's first sentence. The piece notes that managed care has "squeezed midwifery," with many insurers excluding midwives from their network provider lists. Midwives argue they actually save insurers money by using fewer invasive, expensive procedures such as Caesarian sections (which the article might have noted can also mean better patient outcomes). Insurers counter that in a "large percentage" of births that start with nurse-midwives, a physician is ultimately involved, and insurers may end up paying for both.

Recently, several hospitals have made changes that effectively limit the number of births that nurse-midwives can perform. The hospitals cite malpractice factors and a growing number of high-risk pregnancies. Some midwives argue that the changes relate to physician fear of competition, hospitals' desire for higher profits at a difficult financial time, and defensive care; the piece ends with a quote from a midwife who notes that hospitals are more likely to be sued for not performing a Caesarian than for performing one.

The piece reflects input from several nurse-midwives, insurers, hospital officials and one patient. The one major group not represented--at least overtly--is physicians, an extremely rare occurrence in a health care article. Because obstetricians are clearly an important part of the relevant picture, the piece should have quoted at least one to gain his or her perspective on issues like OB-midwife collaboration, competition, and the relative merits of care provided by the two groups of professionals, issues that the article might have developed more in general. The piece might also have made clear that most of those who choose nurse-midwives are not simply afraid of technology and men. Certified nurse-midwives, who typically have graduate degrees, provide highly skilled care that can offer significant health advantages throughout pregnancy and delivery.

See Richard Pérez-peña's article "Use of Midwives, a Childbirth Phenomenon, Fades in City" in the March 15, 2004 edition of the New York Times.