Chile Has Far More Midwives and Far Fewer Maternal Deaths Than the U.S.

Unlike other high-income countries, the United States doesn’t systematically incorporate midwives into health care. It’s one factor in our incomparably high maternal mortality rate — 33 deaths for every 100,000 live births, by far the highest of any high-income country. For Black women in the U.S., it’s more than double that number.

In Chile, where midwives provide services at all levels of maternal care — and even primary or tertiary care — the maternal mortality rate is 14.3 deaths per 100,000 live births, less than half the U.S. rate and trending downward since the 1990s. The country saw a more than 50 percent reduction in maternal deaths between 2000 and 2020, despite a slight increase during the COVID-19 pandemic.

There’s ample evidence that when midwives play a central role in the provision of maternal care, patient satisfaction is higher, clinical outcomes for parents and infants are better, and long-term costs are lower. Midwives are also associated with fewer cesarean sections, lower preterm birth rates, lower episiotomy rates, higher breastfeeding rates, and a greater sense of respect and autonomy for the patient. In the U.S., states where midwives are most integrated into maternal health care have better outcomes, including lower C-sections, preterm births, and neonatal deaths.

While greater use of midwives alone won’t eliminate maternal deaths, Chile shows us their greater participation in health care could help us avoid many preventable deaths in pregnancy and childbirth.

The Critical Role of Midwifery in Chile

Midwifery has been embedded in Chilean health care for nearly two centuries. The practice emerged out of the need for local midwives to assist Spanish colonizers without families in Chile during childbirth. Then in 1834, shortly after Chile declared independence, the first school of obstetric midwifery was established to address high rates of maternal and infant mortality across the country. Today, midwives are integrated throughout the health system, providing primary care, obstetric and gynecological services, and tertiary care in emergency departments.

Midwives must complete a five-year, competency-based education program to provide care. Their practice is regulated by the Chilean sanitary code alongside other health professions, and they are empowered to make independent care decisions. Midwifery is also covered under the country’s universal public health insurance program, ensuring it is accessible to all Chileans, regardless of their financial status.

Chile now has one of the highest rates of midwives per live births compared to most other high-income countries — 80 licensed midwives for every 1,000 live births. Under the Chilean Women’s Health Program, more than 90 percent of tasks in several health services are carried out by midwives, including prenatal, obstetric, and gynecological morbidity care, breastfeeding consultation, and family planning services. Midwives conduct more than 70 percent of deliveries in the public system and are legally authorized to administer labor-inducing drugs, uterine retractors postpartum, analgesic drugs, and some antibiotics. In their role as primary care providers, midwives screen for physical, mental, and environmental factors that impact people’s health, and they make referrals to psychologists and social workers. Currently, midwives are being trained to detect and prevent domestic violence.

The State of U.S. Midwifery

The U.S. has just four midwives for every 1,000 live births, one of the lowest rates of any high-income country, and they are not commonly integrated within health care delivery systems. Here are some of the reasons why:

• Scope-of-practice laws. State and hospital policies often limit the full scope of midwives’ capabilities. About half of states do not allow midwives to practice autonomously, meaning they cannot provide care they’re trained to provide without the supervision of a physician.
• Low reimbursement rates. Midwifery is inconsistently reimbursed by Medicaid, which covers two of five births as well as the vast majority of women who die from maternal complications. While state Medicaid programs reimburse midwives with nursing degrees, only 18 states and the District of Columbia reimburse certified midwives (CMs). CMs lack a nursing degree but they have the same competencies as midwives with nursing degrees, are required to pass the same board exams, and have the same scope of practice, including prescribing. Private insurers may or may not reimburse midwifery, depending on the plan.
• Payment parity. Nearly half of states still pay midwives 75 percent to 90 percent of the rate physicians receive, despite both providing the same care.
• Racial discordance. Only 7 percent of midwives and 13 percent of ob-gyns are Black, which is particularly troubling considering that the U.S. health care system disproportionately harms Black mothers and birthing people. Demand for midwives, particularly racially and ethnically diverse midwives, is growing but largely unmet. Research shows that when midwives are the same race as the patient, patients experience better health outcomes, as that racial concordance improves trust, communication, and adherence to medical advice.

Chile shows a path forward for the United States. Integrating midwives into the health system and ensuring universal access to their care could save thousands of lives.

The author would like to thank Laurie Zephyrin, M.D., M.P.H., M.B.A., Vice President for Advancing Health Equity, The Commonwealth Fund, Lorena Binfa, Ph.D., Professor in Midwifery and Women’s Health, University of Chile, and Paulina López Orellana, Ph.D., Universidad de Valparaíso, for their review of this Insight.