These groups may be at the leading edge of, a 21st century attempt for women to regain control of maternity care. At Group Health Cooperative, for example, the group centering classes started in January 2013, and already almost a third of pregnant women sign up for them, says Karen McConnell, lead certified nurse midwife of the program.
The economic issues of maternity care are huge. The present system of fee-for-service payments, in which physicians and hospitals are paid for every service they provide, encourage more intervention rather than less: a C-section is more profitable to doctors and hospitals; every dose of pain mediation has a profit incentive; and drugs to induce and speed up labor can add to the bottom line.
"The fee-for-service structure gets in the way of hospitals and communities doing the right thing," says Mason, who wrote an editorial for news@JAMA with a headline that sums up her feelings: "Transforming the Costly Travesty of U.S. Maternity Care." Some of those incentives are changing with the Affordable Care Act. Midwives, who used to be paid at 65 percent of what an ob/gyn is paid for an uncomplicated delivery, are paid, since January 2011, at the same rate as physicians. And maternity coverage will be required when the health care law is fully implemented next year. "I believe this will motivate insurance companies to provide maternity care in a way that's cost effective," Mason says. If insurers begin to use bundled payments—one set fee for pregnancy, rather than a payment for each service—the financial incentives will begin to move toward rewarding low-cost care and high-quality results.
That doesn't mean that pain medication won't be administered, or that C-sections won't be done when necessary or that premature births will be eliminated. Kuelz, 41, had her first child in June and her water broke 29 days before her delivery date. "Being in the group made me confident. I had a sense of knowing that everything was OK because we had talked about so many different scenarios," she says.
Karyn Reinbach doesn't want a C-section, but because she has gestational diabetes, she knows she might have to be induced because of the risk of the baby getting too big. And induced labors are more likely to result in surgical deliveries. "I don't want it, but if it's a question of the safety of my baby, I'll do what I have to do," she says. Her nurse midwife, Japke Buesseler, leads a centering group prenatal class through Women's Healthcare Associates in Portland, Ore., and Reinbach feels well prepared for any turn her delivery will take.
But sometimes, everything goes smoothly. Nicole Beaty just gave birth to her third child. For her first two pregnancies, labor was induced and she had an epidural. "I didn't feel exactly helpless, but I also didn't feel I was making decisions for myself," she says. "Everybody was too quick to go to pain medications." By the time she was expecting her third, she had changed insurers, and Group Health Cooperative offered a centering group class. "They didn't make it seem like you had a disease they were trying to treat," she says.
This time, without any medication, she and her husband talked and even laughed through her entire labor—except for the last two contractions. Those, admittedly, were hard. "But not so much that I couldn't bear it," she says. "I never really knew what my body could do before."
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Corrected on : An earlier version of this story misstated that Jennifer Kuelz had a C-section after her water broke prematurely. She had a natural delivery.