Call the Midwives to Improve Maternity Healthcare

Call the midwives. It is time to call the midwives and to integrate them fully into the US maternal health care system. In fact, it is way past time to call the midwives. They have the knowledge, ability and compassion to seriously address the US crisis in maternal health. Midwives are capable of seriously assisting with the necessary reduction in the scandalously high maternal mortality in the United States. Midwives are experts in the care of normal, physiological pregnancy, birth and the postpartum period. They are aware of the cultural and social contexts of the communities they serve and their education and practice reflect that awareness. Furthermore, they include the whole family in their care practices strengthening the integrity of this important social unit and they provide care based on mutual trust. Midwives know when circumstances deviate from normal when they refer to physicians trained to provide care for complications.

As a nation, we are guilty of not appropriately utilizing the professional skills of midwives. We need to deliberately change our health care system to include midwives so that all women will be able to use their services. Data show that midwifery care is associated with fewer cesarean sections, lower preterm birth rates and lower episiotomy rates and greater respect for the autonomy of their patients.

According to the American College of Nurse-midwives (ACNM) there were 13,524 certified nurse-midwives (CNM) and certified midwives (CM) in 2023. 94% are women and 6% are men. Men are accepted by those they provide care for as they are educated to be caring midwives. Their gender does not matter to those they serve. These midwives are certified after passing a comprehensive examination following a proscribed educational curriculum by the American Midwifery Certification Board. CNMs are individuals who are nurses prior to obtaining their midwifery education, while CMs are individuals who are not nurses but who have other educational experiences. The midwifery courses are at the graduate level. Currently there are forty accredited programs in the US offering programs leading to this certification. All are at the master’s degree or higher level. About 84% of CNMs and CMs have master’s degrees while the rest have doctorate degrees. Most of the graduates of these programs practice in hospitals, while some practice in birth centers and attend home births. The standards for the education and certification of CNMs and CMs are identical. There are currently also about 2600 actively practicing Certified Professional Midwives in the United States. There are eight schools of midwifery and they offer BS and MS degrees. They are accredited by the Midwifery Education Accreditation Council. Most of the graduates of these programs practice in the home and community environment. Following successful completing of the required courses, the candidate midwife must pass a certifying examination given by The North American Registry of Midwives (NARM). NARM also will certify as a Certified Professional Midwife an individual who has received an apprenticeship education or who has attended a school that is not yet accredited. In that case, the candidate applies and goes through a Portfolio Evaluation Process to determine the quality of the educational experience.

Midwives attended 12% of all United States Births in 2023. While this is an increase over recent years this percentage is abysmal compared to that of other developing countries, all of which have superior maternal mortality rates compared to that of the United States. The United Kingdom has 41,716 midwives as of March 2023; Germany has about 26000 midwives, France has 23503 and Poland has 22,743. Japan has 37,740 midwives while the Netherlands has 4,345 active midwives currently. The Netherlands, a smaller country that the United States has a much higher ratio of midwives to physicians than the United States, however. In all these countries most births are attended by midwives. It is difficult to compare the statistics completely, as birth registration and data collection are not completely comparable. For instance, in Japan, midwives attend labors and births but the birth certificate is often signed by the physician. The most important point however, is that in all the countries listed in comparison to the United States have much lower maternal mortality rates than that of the United States. Japan and the Netherlands have maternal morality rates of 4/100,000 births. The maternal mortality rate in France is 8/100,000 and the UK is 11.56/100,000. Contrast these rates with the overall maternal mortality rate for the United States in 2021 of 32.9/100,000 and a maternal mortality rate of 69.9/100,000 births for blacks and the picture of how we stack up on both the use of midwives and maternal mortality is not good. Midwives are educated to include the mother and her extended family in the whole process, they are community centered as well and consider the whole person in the planning of the maternity care process as they are educated to view pregnancy, birth and the postpartum period as a normal physiological process. They spend time teaching mothers and the process of pregnancy and birth and the support the mother emotionally. They spend time teaching newborn care and breastfeeding. They strive to create trust between themselves and the childbearing family. Finally, outcomes for normal pregnancies attended by midwives are excellent as shown in multiple studies.

There is a discussion among some state authorities and some physicians who worry about “scope of practice”. The scope of practice for the midwife is normal pregnancy and birth and the individual wellness. They are educated to be acutely aware of any deviation from normal. When physicians work with them as members of the health care team respect their expertise trust develops and the whole concern of the scope of practice cutting into that of medicine is not an issue.

Why did the United States not develop a heath care system that integrates midwifery? It is rather complex but much of the reason has to do with our history. In our colonial period when we were all British subjects, midwives were important and practiced freely and were respected by physicians. Midwives were educated by the apprentice system, but so were physicians. In the mid-1800s formal medical education in medical schools became established. They were all male. When departments of gynecology started to be formed, the concept of the male-midwife or obstetrician was initiated and became fashionable. The United States did not bring midwives into the educational system as happened in Europe. The result was that physicians competed with midwives for the care of childbearing women. In the south, physicians cited the poor outcomes of midwifery care. Many of the midwives were black women and they were pushed aside by the medical establishment. Midwives were blamed for poor outcomes when these outcomes were often due to factors such as poor nutrition and infection and other causes not related to the skill and apprenticeship education of the midwives. The same dynamic occurred in the north as immigrants from Europe came to northern cities. The living conditions of the tenement dwellings of these cities was the cause of high rates of maternal and infant mortality among these newly arrived persons and not the skill of the midwives that immigrated with them. Nevertheless, the medical establishment attacked midwives. The Flexner Report of 1910 aimed to improve medical education and establish the biomedical basis of healthcare. The report was important in improving the quality of medical education in the United States but it had distinct downsides. For instance, in was the basis for the movement of hospital births rather than births at home in the community. Pregnancy and Birth became a medical condition not a normal process. And midwives were OUT. This unfortunate history is still a part of our consciousness.

Current challenges to the integration of midwifery care into our maternity health care system are multiple. Not all insurance policies cover midwifery care. Some insurance companies do not list midwives in provider directories. While all 50 states recognize midwives there are variations by states as to the scope of practice and whether their work needs direct supervision by a physician. Students of midwifery face difficulties obtaining education, because of costs, or difficulties of obtaining adequate clinical experience placements. There is a lack of federal funding for midwifery education, although this is increasing. Finally, there is inequitable Medicaid reimbursement for midwives. There is a great need for more midwives of color and midwives from underserved communities. It has been shown that when a midwife is a member of the community served trust is increased and birth outcomes are improved. When midwife students are in educational situations along with medical students, they learn to respect each other the unique skills sets they bring to the health care team. Thus, there is an essential need to providing ways that midwifery students and medical students can learn together. There are places where this is happening and these programs need to be increased. Finally, there needs to be a new economic paradigm for the analysis of the cost of providing maternity care. Preventive care needs to be rewarded and business schools need to be involved in the evaluation of the current costs of care. The federal government has recently passed bills that provide for increased support for midwives but more needs to be done.