Nonphysician Clinicians


I recently watched a video advocating for increased use of midwives during births.  There is little doubt that using a midwife reduces costs.  In addition, many studies have shown that home births with midwives have comparable health outcomes to those in the hospital setting.  In fact, even births using non-nurse midwives have  health outcomes similar or better to when a doctor is involved.

What was surprising about the video was the following observation: 33.7% of Massachusetts births in 2007 were caesarean sections.

Why are there many caesareans?  Dr. Gene Declerq claims the reason is the cascade of intervention.  Dr. Declerq defines this term using the following scenario: “…they come in and they’re relative low risk, but to be cautious, they put a fetal monitor on them…because things do not appear to be going as quickly as they would like, they induce them or stimulate the labor.  And then because the contractions–as a result of the induction–become very strong, they have to do an epidural to try to relieve the pain from those now stronger  than natural contractions…that may slow labor a little further and then they have to keep adding intervention upon intervention to the point where at the end, somebody says ‘we’re going to do a Caesarean.  Thank god we’re able to do the Caesarean’ whereas if they hadn’t start that series of interventions in the first place, we may have never gotten to that point.

An economist would simply claim that physicians do Caesareans because they are revenue enhancers.

Why aren’t midwives more popular?  Couldn’t midwives be the first option and only if there are problems would the patient be transferred to the hospital?  One reason is that obstetricians want to protect their turf.  Having midwives perform more births will not only take a large chunk of the birth market share, it may also drive down price.

Economists may to often run to the conclusion that financial incentives are the sole driving factor motivating human behavior.  In this case, however, one cannot help but arrive at the conclusion that hospitals and physicians have made giving birth a high-cost, high utilization process to increase their revenue.


  1. I’m no expert on this subject by any means, but I think that the issue of home vs. hospital birth is a bit cloudier than the way it’s presented here. The first issue is that midwives in Canada are more tightly regulated and generally receive more training than is required of midwives in the US, meaning that the comparison isn’t “apples to apples” in some of the studies you link to. The research on relative safety cuts both ways; Amy Tuteur (who blogs at Skeptical OB) discusses this a fair bit.

    As for incentives for OBs to perform C-sections, the answer that you’d get from many OBs is that no one ever gets sued for performing one. A financial incentive of a sort, yes, but motivated perhaps more by fear than avarice.

    I agree that non-physician providers have an important role to play in improving healthcare access going forward. The case for midwives, however, would be strengthened if their training were commensurate with that of midwives in the countries from which the favourable safety data has been obtained.

  2. The cost to a society of even a single child birth defect caused by delivery in the outpatient setting is enormous given the lifetime costs…In addition, transferring complicated deliveries is not in most cases viable which is why it is not done (i.e. the delivery process is extremely time sensitive in many cases such as cord strangulation)…Most people who tend to believe that C-section rates are increasing due mainly to provider revenue optimization have also never had to face the situation in which there is a fetal heart rate monitor in place that is giving off abnormal results (very common) and a trial lawyer will immediately ask why an emergent C-section was not done if a complication occurs. In this situation, an ob gyn will not bear the increased risk in exchange for no upside and considerable downside (lower payments). Possible solution (other than obviously tort reform) would of course include not having such pointless “preventive” monitors in place that spur costly interventions. Unfortunately, that is not possible thanks to the legal and regulatory climate as well as the glorification of preventive medicine…

  3. Also given the above, payment reform or bundling wont really alter the incentive structure in place and might in fact increase it given that once on salary the physician’s willingness to wait out long processes like birth typically would decrease in comparison to a quick 1 hour operation…Finally, these studies of midwives are ridiculous since they cannot/do not control for the patient population (which overwhelmingly determines complication rates)…For all this talk of market protection, I would guess most economists actually use midwives less often than the general population for their or their spouses’ births…

  4. BBC News had an article a few days ago on this, quoting a study of 550K births in the US and EU. While there was a statistically significant increased mortality risk from home birth, it should be pointed out the risk is still very low. The things that increase the risk are those that could be dealt with by availability of advanced resuscitation equipment and expertise.

    On the whole home birth is very safe for healthy mothers with healthy babies. However, in that rare case when something doesn’t go right, there’s a delay.

    As you might guess Midwife organizations challenge the research. Eh…

    The Real Deal is to evaluate each woman carefully who wants home birth, and advise them of risk. Ultrasound is the first step.

  5. While the medical costs of a birth defect may be covered by insurance the change in lifestyle and increased responsibility of a child who can not grown to be a self-sustaining adult are costs the family must bear.

    Even with SSI for a disabled child the parents and family will spent the rest of their days worrying about who will care for the child after they are gone.

    Spaces in group homes are limited, as are decent jobs set-aside for disabled adults. The cost of a casearean is nothing compared to lost opportunities for the family and child.

  6. There’s OB/GYN’s protecting their turf, and then there’s the issue of adverse selection. If all ‘normal’ and healthy births went to midwives then liability costs for OB’s would increase because they’d be carrying more of the risky deliveries. And while I believe (and there’s data to back me up) that doctors overblow their risk of lawsuit (, I do agree that somehow, tort law needs to be adjusted to account for that if we as a society want to encourage less procedure-laden births and discourage C-sections.

    This being said by someone who wouldn’t want an OB within 10′ of her during childbirth.

    As for that science-based medicine posting, if one looks at the data on in that article, the first thing that jumps out is that births attended by certified nurse midwives is about have that of MDs. There’s a matter of definition and skill level between CNM’s and lay midwives. The two are often conflated , thus undermining the good outcomes from CNM’s alone. I tend to take her postings with a salt-shaker, by the way.

    I think the more useful meta-anaylses come from EU countries where C-section rates are a lot lower, use of midwives is a lot higher and both infant and maternal mortality rates are lower.

  7. “As for that science-based medicine posting, if one looks at the data on in that article, the first thing that jumps out is that births attended by certified nurse midwives is about have that of MDs.”

    When you work on a labor floor, you see that the CNMs take care of healthy patients. The 27 weekers go to the OB/GYNs. You need to control for selection bias.


  8. Um, Steve… if you read my comment, that’s what I talk about in the first paragraph: that somehow we need to deal with the fact that OB’s get ‘high risk’ births, if midwives get the ‘low risk’ births, thus skewing their outcomes (that’s what adverse selection).

    On the other hand, I’d argue there’s also been ‘high risk’ creep – in other words, more people being classified as ‘high risk’ based on set criteria and not taking into account individual variation. Do we really need a 29-31% C section rate in this country? I highly doubt that one third of all women giving birth are in need of surgery in order to deliver. So, extrapolating from that, probably more than half of laboring women receive some sort of obstetric intervention. So, I think you’ve created some control for selection bias in an N that large.

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