Editor’s note: This story first appeared in the Hill Country News.
It’s the kind of coincidence that only seems to happen in the midwife community. Both certified professional midwife Chenoa Hamilton and her business partner, naturopathic doctor Dr. Katina Martin, are due to give birth within days of each other. While the pair usually is busy with home births in the Rutland/Middlebury area, their naturopathic and midwifery practice soon will be on dual maternity leave.
“We’re doing each other’s [homebirths],” said Hamilton.
The timing is fortuitous for financial reasons, as well. Most Vermont insurance companies only will reimburse the pair for a home birth if Martin, the doctor, is present.
The companies often accept a naturopath’s credentials for reimbursement, but refuse to pay for home birth if only a certified-professional midwife attends a birth. If Hamilton weren’t going on maternity care herself, she might have been forced to shutter her practice anyway until her partner could help with births again.
The insurance coverage for Martin is a boon to their business, Hamilton said. Lack of insurance coverage drives away many potential clients for many midwives. And Medicaid pays some expenses for homebirth, but often not enough for low-income people to pick it as an option over 100 percent coverage for giving birth in a hospital.
“We’d had a few people who have had to choose the hospital and they don’t want to,” said Hamilton.
Gov. Peter Shumlin is expected to sign the bill into law on Wednesday would mandate insurance coverage for all homebirths attended by certified professional midwives. Proponents say the bill will expand birth options and drive down maternal health costs, but critics say that the bill only would endorse a medically-risky practice.
Push for Midwife Compensation
The bill has become somewhat of a crusade for Cassandra Gekas, Health Care Advocate for the Vermont Public Interest Research Group, a consumer and environmental advocacy organization.
During discussions with health care stakeholders in the recent effort to bring single-payer health care to Vermont, Gekas was surprised to learn about the hurdles Vermont women face to give birth naturally. Vermont’s progressive reputation doesn’t always hold up when it comes to birth, Gekas said.
While Vermont enjoys lower Cesarean-section rates than neighboring New York, Massachusetts and New Hampshire, the state’s 2009 C-section delivery rate hovered just over 27.9 percent, according to preliminary data from the Centers for Disease Control. That’s up from 16 percent in 1996, an increase of 62 percent.
The World Health Organization says national C-section rates should range between 10 percent and 15 percent to avoid increased rates of maternal and infant mortality. The national C-section level was 32.9 percent in 2009, according to CDC data.
Despite these high rates of medical intervention, the United States lags behind other industrialized nations in infant mortality, according to the United Nations. The U.S. ranks 30th in infant mortality, according to CDC data, wedged between Poland and Slovakia.
Gekas says the legislation is an extension of the recent health care reforms passed by the legislature.
“The bill fulfills the promise the Vermont legislature made to Vermont mothers,” Gekas said.
Women who choose to give birth at home or in freestanding birth centers often do so to avoid unnecessary medical procedures, say birth advocates. An added bonus is that homebirth can save costs, Gekas said. A recent study by the state of Washington showed homebirths saved the state $473,000 every two years. The state long has required insurance companies to cover home births.
“In terms of cost, maternal care is a low-hanging fruit,” she said.
Certified professional midwives in Vermont hope the bill will continue to legitimize homebirth, said Erin Ryan, a spokeswoman for the Vermont Midwives Alliance and a homebirth midwife.
“We’ll be seen as legitimate providers,” said Ryan.
In recent years, midwives and their allies have launched a national campaign, dubbed the Big Push for Midwives, to ensure the legality of homebirth in each state. Until recently, homebirth was considered outside the bounds of the legal system in most states. Other states had passed laws allowing homebirth to be attended by midwives with nursing degrees, but not those attended by certified professional midwives, or midwives who have gone through a non-nursing training and a certification process.
The Big Push for Midwives has succeeded in raising the total states that regulate and license professional midwives to 27. Last year, it organized a successful campaign to pass a New York law to allow professional homebirth midwives to practice without needing a written agreement with physicians.
When states clarify the legality of homebirth, the insurance companies often fall in line, said Kathleen Prown, the Big Push campaign manager. But only four states have passed laws with language pushing or mandating insurance companies to cover certified midwife-attended homebirths. Two of those four states are New York and New Hampshire.
“Vermont is kind of out in the lead on this,” said Prown.
Legitimizing a Risky Practice?
The bill passed in the Vermont Senate, but now must make its way through the Vermont House, and advocates for midwives worry it may not make it through the needed committees before the legislature adjourns.
The bill’s fate is still up in the air. While several members of the House have had homebirths, some House members are openly hostile to the bill.
The bill also has its detractors in the medical community, Gekas said.
“What we’re seeing in Vermont and nationally is a pushback from obstetricians and gynecologists,” she said.
The bill is opposed by the Vermont Medical Society. Paul Harrington, Vermont Medical Society president, argued that homebirth is too risky of a procedure to require insurance companies to cover it. He cited a recent study published in the American Journal of Obstetrics and Gynecology that showed homebirths suffered a three-fold increase in infant mortality rates over hospital births. The study, led by Maine Medical Center researcher Dr. Joseph Wax, is a meta-analysis of studies comparing the medical outcomes of birth at home and in hospitals.
Harrington fears legislative action mandating insurance coverage for homebirth will cause Vermonters to think homebirth is safe. If the legislature passes a bill, it will endorse a risky practice, he said.
“We’re concerned it somehow creates the impression that homebirths are the safe alternative to hospital birth,” Harrington said. “It creates a false sense of security.”
Insurance companies also have expressed misgivings to the Vermont legislature about covering homebirths, said several people familiar with the Senate hearings on the bill. Attempts to reach representatives at Blue Cross/Blue Shield Vermont and Cigna Health Care in Vermont were unsuccessful.
But the meta-analysis cited by Harrington has been criticized by many in the homebirth and medical community for questionable methodology, and some are trying to get the journal to redact it. The studies cited showing increased infant mortality failed to distinguish between unplanned and planned homebirths, argues Dr. Michael Klein, a birth expert who has served as the Director of Maternal Health at the University of British Columbia. When planned homebirths are analyzed, Klein said, the medical outcomes are as good as or better than hospital births.
Even with unplanned homebirths factored into the total, the threefold increase in infant mortality is not as large as it seems, said Gekas. The rate goes from 0.02 percent to 0.06 percent, she said.
“It’s still less than 1 percent,” Gekas said.
And Ryan says the main argument against the bill, that it would legitimize homebirth, is moot. That debate was over when the legislature voted to license homebirth, she said.
“Vermont’s already decided we’re safe,” Ryan said.
Fears of Joining the Fold
Insurance coverage may not be the road to Easy Street for midwives, at least if Hamilton’s experience with Medicaid is any indication.
Medicaid reimbursements don’t cover the costs of homebirth, she said. Low-income Vermonters still must pay for much of the care out of pocket.
“If we were only to take what Medicaid reimburses for us, no one would even make a living,” said Hamilton.
Hamilton has colleagues in New Hampshire who have been less than thrilled with insurance coverage won in the Granite State.
“A lot of them have given up taking insurance because you can’t survive,” she said.
Ryan also began with mixed feelings about the bill, worrying about the possible loss of autonomy in her practice to insurance companies. But she says she now thinks the bill will help Vermont’s midwives.
Gekas understands the concerns of midwives, but wants to assure them that they can always opt out of the insurance system. She agrees that insurance companies probably will underrate the services provided by midwives initially, but mandating insurance coverage will make sure midwife reimbursement is reviewed by the state’s insurance governing board.
“It makes sure midwives are on the radar screen,” Gekas said.
She also hopes to work with health-care stakeholders in the state for an omnibus women’s health bill that would improve further maternal health and the standing of midwives in the state.
In a way, it’s ironic that the bill focuses on insurance companies, she said.
“We’re trying to get insurance companies out of the state,” Gekas said. “That’s the ultimate goal.”
