Access to Maternity Care in Alabama: an Ob/Gyn’s Perspective
By: Dr. Jesanna Cooper, Simon Williamson Clinic Obstetrics and Gynecology
For over 40 years, it has been illegal for Certified Professional Midwives (CPMs) to deliver babies in Alabama. In the midst of a maternal health crisis in which Alabama has some of the worst maternal health outcomes in the country, Alabama is now poised to begin licensing midwives and stop criminalizing their work. We asked a couple of our friends in Alabama to share their thoughts:
Dr. Cooper’s story:
I am a physician who loves midwives. Midwives were kind to me during the dark days of residency training. They supported and comforted me on the journey to physician-hood just as they nurtured other women on their pregnancy and childbirth journeys. My midwife colleagues now support me with understanding and validation, often picking me up and setting me squarely back on my path. It’s what good midwives do. The midwifery model of care is both empowering and compassionate. It is low cost and high touch. This model is the solution to Alabama’s current maternity care crisis — if we have the political and financial will to support it.
Alabama has an access problem. We have both an access to care problem and an access to quality care crisis. Access problems lead to outcome problems. In Alabama, 33 of our 67 counties have NO maternity care providers. It should, therefore, not surprise anyone that we have poor infant and maternal health outcomes with disparities clearly delineated in black and white.
Infant Mortality: 6.5/15.1% per 1,000 live births
Preterm Birth: 10.4/15.2%
C/S rates 35.6/ 37.2%
These statistics are more in line with the outcomes in Bahrain, Sri Lanka and the Ukraine than with the more developed countries of Canada, U.K., and Japan. The crux of our access/ outcome problem lies with where we invest our healthcare dollars. We spend enormous amounts on maternity care. But, the majority of those costs go towards 2–3 days of hospital care. Meanwhile, the bulk of maternity care occurs outside the hospital — pre and postpartum.
So, we have an access to quality care problem because we don’t invest in the largest portion of maternity care. In Alabama, we don’t invest in providers and models that have been shown to improve access and outcomes. There is no reimbursement for group prenatal care, doulas, IBCLCs (International Board Certified Lactation Consultants), CLCs (Certified Lactation Counselors), peer counselors, or mental health services (including Ob-Gyn visits for peripartum mood disorders.) There is low and inconsistent reimbursement for midwives, physical therapists, and medical care required outside of the very narrowly defined “pregnancy related” care. What is covered? Delivery! The majority of the bundled provider payment goes to delivery — the quickest, most easily scheduled delivery will make those reimbursement dollars go the furthest. And that is an important calculation because outpatient practice is becoming unaffordable. Overhead costs go up, reimbursement goes down and physicians look for other ways to pay back their school loans.
Physicians are pushed into hospital employment. And, hospitals are profit driven, not quality driven. Spending the majority of maternity care dollars on hospital care exacerbates our quality problem. It also exacerbates our access problem. Hospitals want to invest in the high intervention, high intensity care that pays the most: laborists, OB-EDs (Obstetric Emergency Departments), and NICUs are all good for business. Physicians can earn more providing this type of care and leave their practices to become laborists. In Alabama, this leaves no one to provide prenatal care which creates an even greater need for the OB-ED. Providing high intensity care is expensive. So, hospitals consolidate service lines. Here, this means moving services from black areas to white and from lower income zip codes to higher. It means closing hospitals in rural areas as well as “urban deserts.” It means we have 7 full service L&D (labor and delivery) hospitals with NICUs fighting for business within a 15 mile radius and 33 of 67 counties with no maternity services at all.
Alabama needs reimbursement and legislative reform that supports a pyramid structure of maternity care. The base of that care is formed by community health workers bringing home based care to our rural areas and urban deserts: CPMs, doulas, breastfeeding peer counselors, home health RNs and physical therapists. The next layer includes CNMs (Certified Nurse midwives) and CLCs providing group prenatal care, birth center care and lactation support. A significant portion of our maternity care dollars should go to supporting these base tiers. The next tier includes pediatricians, Ob-Gyn generalists, and family medicine physicians backing up CNMs in a hospital setting with c/s capabilities, nursery support and IBCLCs. The top triangle of the pyramid includes MFMs (Maternal-Fetal Medicine Specialists), OB-ED laborists, intensivists and ICUs, psychiatric units, and NICUs. We need telemedicine and transport services so that every mother/ infant dyad is cared for in the appropriate setting. These services are the mortar holding the pyramid together.
If we continue to only support and reimburse services at the tip of the maternity care pyramid, the system will continue to be structurally unsound, and we will find ourselves digging sick and dying mothers and babies out of the rubble.