A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies

ProPublica (Feb. 22, 2018): A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies, by Nina Martin:

The results of a five-year study, conducted by researchers in both the U.S. and Canada, on the effects of midwifery on maternal and infant health are in. The study was published in the peer-reviewed journal PLOS ONE; it analyzes hundreds of laws throughout the United States that dictate what a midwife can and cannot do when it comes to prenatal care and the birthing process. 

'We have been able to establish that midwifery care is strongly associated with lower interventions, cost-effectiveness and improved outcomes,' said lead researcher Saraswathi Vedam, an associate professor of midwifery who heads the Birth Place Lab at the University of British Columbia.

The midwife model emphasizes community-based maternal and infant care along with avoiding any unnecessary, and potentially dangerous, interventions. Midwives have long been widely embraced in Europe as a positive component of maternal care. In the U.S., though, midwives often represent a "culture war that encompasses gender, race, class, economic competition, professional and personal autonomy, risk versus safety, and philosophical differences." 

The title "midwife" can have multiple meanings, ranging from "certified nurse-midwives," to "direct-entry midwives," to "lay midwives." Depending on the title and the state in which the midwife works, the midwife will have a different level of training and may or may not be licensed or regulated by the state. 

This new study indicates, though, that midwives may be part of the answer to the U.S.'s problematic infant and maternal mortality rates. Severe maternal complications have sharply risen over the past 20 years, and maternal care is seriously sparse in certain areas of the country. "Nearly half of U.S. counties don't have a single practicing obstetrician-gynecologist." 

While midwife regulations vary widely among states, the study shows that states that have more fully integrated midwifery systems within their health care have significantly better outcomes for mothers and babies. States with restrictive midwife regulations--like Alabama, Ohio, and Mississippi--regularly score much lower on tests of maternal and neonatal well-being.

Alabama, which has the worst infant mortality rate in the country, has long had strict midwife regulations, "reflecting attitudes that wiped out the state's once-rich tradition of black birth attendants." Alabama lawmakers, though, recently passed a bill legalizing certified professional midwives, taking one small step toward the process of greater midwife integration, and, hopefully, improved maternal and infant health care across racial and economic lines. 

Access to midwifery is often split among racial lines, as many of the states with the worst outcomes (and higher levels of opposition to midwives), including Alabama, have large black populations. The study suggests a correlation between improved access to midwifery and reduced racial disparities in the maternal health care field.

Jennie Joseph, a British-trained midwife who runs the Florida birthing center and nonprofit Commonsense Childbirth affirms this:

“It’s a model that somewhat mitigates the impact of any systemic racial bias. You listen. You’re compassionate. There’s such a depth of racism that’s intermingled with [medical] systems. If you’re practicing in [the midwifery] model you’re mitigating this without even realizing it.”

The study, though, does not conclude that better midwife access will directly lead to better outcomes or vice versa. It acknowledges that many other factors also affect maternal and infant health among states, including access to preventative care, insurance, and rates of chronic disease.

Nonetheless, maternal health advocates have long recognized the benefits of midwifery and this is not the only study to highlight the positive effects of supporting midwives. A 2014 study found that integrating midwives into health care could prevent more than 80 percent of maternal and infant fatalities worldwide, in both low and high-resource communities. Even in the U.S., organizations such as the American Congress of Obstetricians and Gynecologists have begun embracing nurse-midwives despite lingering skepticism by many.