Published on October 01, 2003
Local Hospital To Curtail Midwives' Responsibilities
With technology's role in birthing on the rise, the need for midwives may be diminishing.
By KATHLEEN CARR
Spectator Associate News Editor
The midwife's role is to provide physical and emotional care to a woman during the birthing process--a job for which midwives must now compete with doctors. Starting today, the midwife's involvement in the delivery room will be severely curtailed at the Allen Pavilion, a community hospital near Baker Field. Allen Pavilion is a regional branch of the larger New York-Presbyterian hospital.
Allen Pavilion midwife Janet Brooks said that her practice was informed last May that midwives would no longer be performing deliveries, as determined by a change in hospital policy.
"We were told at the time that 85 percent of the patients were at-risk, and that we were no longer eligible to assist them in the delivery room," she said.
Brooks said that numerous petitions to the hospital for the at-risk statistics have been unsuccessful.
Helen Morik, vice president for government and community affairs at New York-Presbyterian, said that data indicating the percentage of at-risk Allen Pavilion patients is confidential. Brooks speculated that the data does not exist.
"We don't know the real reason why this is happening," Brooks said.
Morik said that the hospital's new policy is based on the quality of healthcare delivered to its patients.
Critics are skeptical that the abrupt change in protocol was not completely unrelated to a healthcare lawsuit involving Allen Pavilion and Columbia University earlier this year. The lawsuit, which Columbia settled with the U.S. government for $5.1 million, alleged that Columbia doctors working at Allen Pavilion had submitted fraudulent claims to Medicaid for services that midwives had performed.
In the alleged cases, the midwife would deliver the baby while communicating with the on-call Columbia physician about the patient's care. The University posited that it was acceptable to bill for the doctor's supervision in those situations; the government determined otherwise.
Some say that Allen Pavilion's recent change in protocol is designed to eliminate any chance of the circumstances that precipitated the lawsuit arising again.
In a June 15 New York Times article, a hospital senior vice president denied that the lawsuit had anything to do with the change in midwifery protocol.
Allen Pavilion is a community hospital located in a mostly Dominican Washington Heights neighborhood. Officially, the hospital said that an increasing number of its patients are at-risk, meaning that they are more likely to experience problems during labor. These at-risk patients, the hospital said, need more medical attention from a physician and less midwife participation.
In response, some obstetrics experts assert that high-risk women need midwifery care more than low-risk women do.
"The rationale presented--which is that midwives are not qualified to serve at-risk women--is, for me, very difficult to grasp," said Dr. Ruth Lubic, TC '59, '61, '79. Lubic, who is the 1997 winner of the MacArthur Foundation Fellowship, opened the first birthing center in the country in the Bronx in the mid-1970s.
Dr. Allan Rosenfield, dean of the Mailman School of Public Health and DeLamar professor of public health, spearheaded a 1989 study which indicated that midwifery care of high-risk women is both acceptable and effective.
Some midwives say that the new policy enables physicians to dominate obstetrical territory that used to be in the realm of "collaborative care." Under that model, doctors and midwives would work together to assess a patient's healthcare.
Obstetrics patients at Allen Pavilion who are now being referred to medical attention would not have been advised as such under previous policy. The new protocol mandates that patients who have had C-sections in the past or patients who have a body mass index over 30, for example, must immediately be seen by doctors.
"In some cases, these are patients who could be co-managed.
Instead of receiving care from both a doctor and a midwife, they must automatically be sent to the doctor," Brooks said. For some patients, this referral is highly offensive: it labels them as unstable patients, even when they might be capable of a normal delivery.
Critics of the abrupt change in policy emphasize that doctors will now be able to bill for premium fees. Dr. Nicholas Cunningham, Columbia emeritus professor of clinical pediatrics and clinical public health, said he fears that Allen Pavilion obstetrics procedures will become more "medicalized," encouraging dangerous--and expensive--Caesarean sections over natural deliveries.
In 2002, the total Caesarean delivery rate of 26.1 percent was the highest level ever reported in the United States, said the National Center for Health Statistics in a June 25 statement.
In addition, the number of Caesarean births to women with no previous Caesarean birth jumped seven percent and the rate of vaginal births after previous Caesarean delivery dropped 23 percent. The Caesarean delivery rate has been on the rise since 1996.
The majority of documents endorsed by the American College of Obstetricians and Gynecologists indicate that under normal conditions, C-sections are more dangerous than vaginal births. Any increase in the C-section rate at Allen Pavilion is likely to provoke a new wave criticism from the policy's opponents, simply because Caesarean operations are more costly for the hospital than vaginal deliveries.
"The more procedures you order, the more money you can make," said Kitty Ernst, MSPH '59, who began the Columbia-Presbyterian midwifery program. "All of these things are swirling around, and at the bottom of it all, there's money."
Morik said that there has been a lot of miscommunication regarding hospital finances over the past few months.
"The issue was never one about money. I think that maybe we need to do a better job of indicating that to our patients," she said.
Recently, the hospital maintained that midwives will continue to perform deliveries for obstetrics patients with no risk factors, or about 10 percent of Allen Pavilion deliveries.
But the midwives have been told they will be doing deliveries entirely at the discretion of the doctor. This is "a difficult position in which to put a licensed professional--one professional telling another how to practice," Brooks said.
Under the hospital's current policy, it is still acceptable for a woman to ask for the care and involvement of a midwife, especially during the pre-natal stage.
"It's just the actual delivery, when, quite frankly, you just want the baby out. And having a competent doctor is very reassuring," Morik said.
The midwives at Allen Pavilion are unionized workers whose contract ends in December 2004. They speculate that their practice will shrink even more severely at that time.
On a larger scale, midwives across the country fear that they will gradually lose their sphere of influence in obstetrics healthcare.
Ernst said that setbacks to midwifery are being felt all over the United States. Columbia's grassroots support of midwifery in the mid-20th century provided a growth model for practices nationwide. Midwives speculate that Columbia's gradual dissociation from midwifery will encourage a move in the opposite direction.
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