Call The Midwife Back : The Indicator from Planet Money For more than three decades, it was illegal in Alabama to have your baby delivered by a midwife. But last year the state finally legalized midwifery and now it could lead to serious cost savings.
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Call The Midwife Back

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Call The Midwife Back

Call The Midwife Back

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Hello, Julia Simon.


Hey, Stacey Vanek Smith.

VANEK SMITH: How's it going?

SIMON: It's going well.

VANEK SMITH: And you are here at THE INDICATOR. And you have brought us a story from Birmingham, Ala.

SIMON: Yes. I just got back from Birmingham, Ala. And when I was there, I met Whitney Jones. She told me about the night five years ago when she was in labor.

WHITNEY JONES: They was telling me that if I didn't have my daughter within the hour, that they was going to have to have a caesarean. And then the doctor literally told me, don't push.

SIMON: That didn't sound right to Whitney. The baby wasn't in distress. She wasn't in distress.

JONES: And I was like, that sound the opposite of what you do when you're giving birth. So soon as he left, guess what I started doing. I started pushing. And next thing you know, she just popped out. He came in, what did you do? I said, nothing.

SIMON: Whitney's daughter Brooke (ph) was born. And in June when I met Whitney, she was eight months pregnant with her second daughter. When Whitney found out she was pregnant this time...

JONES: Excitement was first, and then nervousness. And I was just like, you know, I don't really want to go through what I went through previously.

SIMON: This time around, she didn't want to feel pressure to have a C-section she didn't need. This time around, like her grandmother before her, Whitney wanted a midwife.

VANEK SMITH: But she wasn't sure she could find one because up until last year in Alabama, certified professional midwives were illegal. This is THE INDICATOR. I'm Stacey Vanek Smith.

SIMON: And I'm Julia Simon. Today's indicator - 12. That's the number of certified professional midwives in Alabama. After 30-plus years, last year, the governor signed a bill making midwifery legal.

VANEK SMITH: Midwifery?

SIMON: Midwifery - it's one of my favorite words.

VANEK SMITH: Not midwivery (ph)?

SIMON: Midwifery - you're going to hear it a lot this episode.

VANEK SMITH: Midwifery - all right. I'm in. Turns out, using a midwife can actually reduce costs, and the American health care industry is taking note. Today on the show, decriminalizing midwifery, and the bottom line of birth.


SIMON: OK, Stacey.


SIMON: So I want to take you back to when midwifery was still illegal in Alabama.

CHAUNTEL NORRIS: And it was very under the radar. You know, it was very hush-hush.

SIMON: This is Chauntel Norris, a doula at Alabama's Baobab Collective. She told me about a midwife birth she went to.

NORRIS: It was very, you know, on the down low. You know, nobody - no names are spoken. I will send a smoke signal, and hopefully the midwife will see it and come, you know, because we - you can go to jail for this.

VANEK SMITH: Jail - what? Really?

SIMON: Yes. It was a misdemeanor in Alabama for a certified professional midwife to deliver babies.

VANEK SMITH: Always a misdemeanor?

SIMON: It wasn't always. Midwives used to be legal, but in the '70s, the state stopped licensing them. The argument was that midwives were uneducated, unsafe. And this was often very coded racial language because at the time of the criminalization, many Alabama midwives were black, called granny midwives.

VANEK SMITH: So last year, after more than two decades of fighting, the midwifery advocates got a bill through the Alabama legislature, and the governor signed it, legalizing certified professional midwives.

SIMON: Right. And one of the women who was very happy that day is Sheila Lopez, one of Alabama's five delivering certified nurse midwives. Sheila was excited because she sees midwives as a way to increase maternity access in a state where over half of counties don't have a single birthing hospital.

But there was something else, too - something Sheila knew midwives would bring to the table.

SHEILA LOPEZ: We also do decrease C-section rates.

VANEK SMITH: That is a big one. Several studies, including a five-year study published earlier this year, found midwifery use was associated with lower C-sections rates. Sheila's hospital in Birmingham is one of the few Alabama hospitals that has certified nurse midwives. And they have seen an impact.

Overall, the rate of C-sections at Sheila's hospital is more than 20 percent. But when midwives are involved...

LOPEZ: We have ranged somewhere around the 7 to 12 percent range, and so it is significantly lower for the women that choose midwifery.

VANEK SMITH: And when you compare vaginal birth to C-sections, there is a big cost difference.

DAVID LANSKY: It turns out a C-section is about $10,000 per case more expensive.

SIMON: David Lansky is the CEO of the Pacific Business Group on Health, a nonprofit working with 60 companies, like Bank of America, Boeing, Intel, representing $100 billion worth of health care spending.

A lot of that spending is maternity care. David finds for many of these companies, it's the second-biggest source of health care expenditure. His group has seen these costs go up, wanted to know why.

LANSKY: We discovered there were an awful lot of unnecessary surgeries taking place, causing harm to moms and causing a lot of unnecessary expense.

SIMON: And when you say surgeries, you're talking about C-sections?

LANSKY: Yeah. C-sections in particular.

SIMON: C-sections can be critical for high-risk situations, like a baby in distress. But for women like Whitney, who are low-risk, whose babies are low-risk, those women don't need them.

LANSKY: We are now at about 33 percent of all the births are C-sections in the United States. One of our very large companies - one of our members has a 42 percent rate of C-sections in their population.

VANEK SMITH: That might be too high. One recent study found that once you get above 19 percent of births being C-sections, you don't really see any additional benefits in terms of moms' and babies' lives being saved. So a 42 percent C-section rate could mean a lot of unnecessary surgeries, which, in addition to being very expensive, can also lead to complications.

So in an attempt to cut down on unnecessary C-sections, David's group decided to turn to midwifery.

LANSKY: So we're just trying to, if you like, grease the skids and make it easier for a practice to include midwives and what they offer to their community.

VANEK SMITH: The Pacific Business Group on Health has a tool kit to help obstetricians integrate midwives. They're helping health insurance companies include them in their online provider directories. And they're trying to provide something called bundled payments. Here's the example David gave.

LANSKY: Let's suppose we pay $10,000 for a vaginal birth and 20,000 for a C-section. I'm essentially creating an incentive for doing additional C-sections 'cause the hospital makes an extra $10,000 for every C-section that it does. Instead, I take that combined total money and just average that, I'll come up with a number that is something like $13,000 per case.

SIMON: So this way, the health insurance companies give the hospitals the same set fee, no matter what - C-section or vaginal birth - so the hospital's incentive is to do what's right for the patient, and that includes using midwives.

LANSKY: If it's a low-risk birth, and a midwife is the appropriate level of care for a low-risk mom, then someone who has a bundled payment has an incentive to put those two together.

SIMON: They have an incentive to call the midwives.

LANSKY: Call the midwives.


SIMON: I couldn't resist.

LANSKY: I know. Go ahead.

SIMON: Of course, the U.S. has a long way to go to integrate midwives. For example, in England, midwives attend more than half of births. But in the U.S., they only attend 8 percent of births. In Alabama, it's just 1 percent of births. But Whitney was determined to be in that 1 percent. And if she couldn't find a midwife in Alabama, she was going to get in her car.

JONES: I was being told there wasn't any midwives. I was very close to going across the state line just to give birth to my child.

SIMON: Wow. Where would you go?

JONES: I was going to go to Tennessee.

SIMON: But Whitney made it happen. She found her Alabama midwife, and she found a doula. She got a whole team. She was able to do it all aboveboard. And on June 25, baby Raya was born.

JONES: She won't let me - you want to open your eyes up?

SIMON: She's opening her eyes a little bit.

JONES: (Laughter) She's something else.


SIMON: Whitney says with Raya's birth, with a midwife by her side, this time, no one pressured her to have a C-section she didn't want or need. They just told her to keep on pushing.


THE IMPRESSIONS: (Singing) 'Cause I've got my strength, and it don't make sense not to keep on pushing. Hallelujah, hallelujah.

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