Over the past 2 decades, insurance coverage for midwives who deliver babies outside of the hospital has ebbed and flowed.
In the early 80's one company offered a rebate to people who sought out those services.
But in recent years, the state's major health insurers have declined to cover midwives unaffiliated with hospitals.
That policy affects both of the state's birthing centers.
And as New Hampshire Public Radio's Dan Gorenstein reports without the leading insurance companies support, midwives say it's getting harder to stay in business.
LB Solsky understands the difference between giving birth in a hospital and delivering with a midwife.
Solsky delivered her son Aethan at the Longmeadow Birthing Center in Hopkinton just two months ago.
Her experience at Longmeadow was distinctly different from when she gave birth to her daughter Cadence at a Seacoast hospital.
She says the people at the hospital were very nice, but too clinical.
3:16... once you set foot in this place that mentality takes over. When you come here, it's like a celebration, I don't mean to be hokey, it really is.
Solsky says she prefers the homelike birthing center, where she feels her concerns and wishes are respected.
The only problem for Solsky is cost.
She is still negotiating with the insurance company to pay the bill.
But whatever Solsky's insurance trouble, it is magnified tenfold for her midwife Carol Leonard.
Leonard, who runs the Longmeadow Birthing Center, says it's gotten so bad; she's going to close in January.
She says it's impossible to stay in business if the state's two largest insurers Anthem and Cigna don't cover her.
T. 16
:12...everybody else does pay. Aetna, United, Blue Cross from other states, it's the two giants in the state don't, but the others do the math, and figure out how much they save. And they don't even question. Sometimes it takes a while, but they pay.
The way Anthem and Cigna deal with midwives is complicated.
Both do cover some midwives services.
But providers must meet certain standards.
Anthem, for example, will only pay if a midwife has a nursing degree and is affiliated with a hospital.
If a pregnancy is problem free, Anthem Medical Director John Robinson says being a nurse wouldn't matter.
But he says something can go wrong without any warning.
And that's what he's worried about.
4:19 If that happens, we want our members to be getting services by people who know and trained in those sorts of emergent situations. And it's our contention that having a nursing degree is the minimum threshold to be able to have some degree of comfort a provider will be able to handle that situation.
The other main insurance carrier Cigna also covers midwives.
But it requires is a license from a training facility that is accredited by one of two national organizations.
All these standards are an effort to guarantee the highest quality of care.
But Midwife Leonard says she took a 13-hour state exam to get her midwifery license.
And she thinks a license from the state of New Hampshire ought to be good enough for Cigna.
Company Medical Director Robert Hockmuth says the state license doesn't even register.
21:14...I know we have standards we have developed not just for NH, but on a national level to be objective as possible, and I must confess don't know the detail in how those two relate, and what exactly those standards are.
To Leonard, the insurance companies' policies reflect the disdain the medical establishment has for her trade.
Leonard says she would put her 29 year record of 1200 healthy, happy births up against anyone.
But after all these years, she says she's tired of fighting.
T. 4
4:30 it's the animosity. There is some kind of animosity about what we do. I don't quite get, b/c A, I've proved myself to be a very safe practicioner. And that automatic kneejerk animosity...I'm done, I'm just really done. That barrier. We are providing a really safe environment to give brith, I am just sick of being beat up about it.
Leonard says she has never had a death in her practice.
That's better than the national average.
According to the CDC, there are 3.6 deaths per 1000 deliveries.
Part of that success rate can be explained by midwives only taking the lowest risk cases.
Some insurance companies find these numbers persuasive.
United Health Care, a national insurance company representing some 18 million people, pays for birthing centers and out-of-hospital deliveries.
Spokesperson Deborah Spano says her company is satisfied.
1:44 we haven't found any complications that have resulted in death in the four or five years I've been here. It seems to be very safe, we monitor the outcomes of all our patients to be sure we are providing them with coverage for the safest and best outcomes.
The safety of Longmeadow is beyond doubt for patient LB Solsky.
On top of that, at a time when health care costs are exploding, it doesn't make sense to Solsky why insurance companies aren't more interested in taking advantage of the less expensive birthing center services.
Solsky compares the cost of her daughter's hospital birth to her son's at Longmeadow.
T. 19
7:38 ... Her hospital birth, the 48 hours we were there, without getting stuck with any needle was $6000 dollars. Every bit of care that I received in 3 trimesters, birth and delivery...and milk shakes after he was born was $3,800 dollars. That's the dollars and sense of it...this is efficient.
The state has also considered the savings.
New Hampshire's Medicaid program covers out-of-hospital deliveries.
State officials explain they made the decision to give people greater access to care, but they appreciate that the service is cheaper.
The state's largest insurer Anthem says they haven't done a cost benefit analysis to see how much money could be saved if they paid for out-of-hospital midwives.
But right now, Medical Director John Robinson says there isn't a need to even do one until more people start asking for it.
23:44 to some degree it is a market demand situation. If we had a huge push for us to provide coverage for deliveries done in birthing centers outside a hospital. We would have to a very very thorough analysis of providing that coverage. But we would be willing to undertake such an analysis.
Many midwives and their advocates say the medical profession still clings to the notion that midwifery is inferior.
But Marion McCartney, director of professional services at the American College of Nurse Midwives says it's more complicated than that.
She points out, while the numbers are up, out-of-hospital birth is still only about 1% of the births nationwide.
McCartney says doubts about the profession run much deeper than just the medical establishment.
16:41 some of it is not culturally comfortable for us to deliver outside the hospital. I don't think that physicians are the only ones who feel that way. A lot of people are very uncomfortable with the thought of giving birth outside the hospital. They are very uncomfortable with midwives.
Midwife Carol Leonard admits many people aren't familiar with midwives, and are maybe even a little bit leery.
But it's clear to the 29 year veteran, the insurance companies policies make it unlikely that is going to change anytime soon.
For NHPR, I'm DG.
