The True Cost of Restrictive Healthcare Licensing Laws: Mother’s Lives


Becoming a mother in the United States is risky. Among developed nations, the US has the highest rate of maternal mortality, carrying double the risk than that of France, and 10 times the risk than that of Norway.

Our maternal mortality rates are even increasing. Recently released data from the CDC, show that the US climbed from 17.4 deaths per 100,000 in 2018 to 23.8 deaths per 100,000 in 2020. And for black mothers in the US, the risk more than doubles to 55.3 deaths per 100,000 live births – comparable to the risk of giving birth in under-developed island countries like Tonga or Maldives.

How did becoming a mother in the United States because so perilous?

Is it an issue of first-time mothers becoming older? American parents are waiting longer to have children. However, first-time mothers in countries such as France, Norway, or Japan, are on average 2-4 years older than first-time mothers in the United States.

Is it a spending issue? Individuals on the left tout solutions such as increased funding, new agencies, or even single-payer health care. Yet, we already spend twice as much on obstetric care as other developed countries.

The true problem is that the United States has a huge shortage of maternity care providers relative to the number of pregnancies. We rely almost exclusively on highly trained OBGYN’s for obstetric care, while a tangle of laws limit midwives and birthing centers from meeting the needs of expectant and postpartum mothers.

In countries with lower maternal mortality rates, that ratio is flipped: there are many more midwives than OBGYN’s. Research shows that midwifery care can dramatically lower the risk of maternal death.

At first glance, the research seems counterintuitive. If women are dying from giving birth, shouldn’t we ensure every mother sees OBGYN’s (who are highly trained for emergency response) and not midwives (who have less emergency training)?

But digging deeper into United States’ model, the dilemma becomes clear. First, there are simply not enough OBGYN’s to go around. As a result, an OBGYN’s attention is split by giving unnecessary care to low-risk women, and not enough attention to high-risk women. It is a classic supply and demand issue – but in this case, the cost is in lives.

Secondly, trained for emergencies, OBGYN’s carry an inherent confirmation bias when treating patients. The attitude can quickly lead to a cascade of unnecessary emergency interventions even when birth is progressing safely. For high-risk individuals, that approach makes sense. But for low-risk individuals, the approach causes significantly more harm than good.

Thirdly, most pregnancies are low-risk and can be easily monitored by a midwife with regular blood pressure readings and urinalysis. If a pregnant woman begins showing complications, the midwife could then refer the patient to a specialist.

So how can the US decrease maternal mortality? By untangling our laws that restrict midwives and birthing centers. Currently, 40 out of 50 states have various regulations that restrict the licensing of birth centers, or midwives, or both.

Take certificate of need (CON) laws for example. When new healthcare businesses are forming, many states require the healthcare entities to apply for a “certificate of need” to prove that the community needs the service. However, the board that approves the certificate is filled with the would-be business’ existing would-be competitors.

What if Coca-Cola were able to prohibit Pepsi from entering marketplace by saying, “we have the public’s soda needs covered?” Monopolistic laws are not only unfair, but in the case of maternity care, certificate of need laws have deadly consequences.

Other states have onerous licensing or scope of practice rules for midwives. Some states do not allow Medicaid funds to go to midwives or birthing centers – which makes midwifery unaffordable for most families and puts birthing centers as a competitive disadvantage.

9 of the 10 states with the highest rates of maternal mortality have regulations restricting the promulgation of birthing centers and midwives.

To solve our maternal mortality crisis, we must allow qualified midwives and birthing centers to enter the marketplace.

McKenzie Richards is a Policy Associate at the Pacific Research Institute.

Nothing contained in this blog is to be construed as necessarily reflecting the views of the Pacific Research Institute or as an attempt to thwart or aid the passage of any legislation.

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