We Need More Midwives

In a quiet and dimly lit hospital room, a woman is breathing heavily and crying out saying, “I can’t! This is so hard!” The midwife makes eye contact and reminds the woman that her body is made to do this, she is safe, and she is incredibly strong and powerful. Minutes later, the baby emerges into the world and the midwife encourages the new mother to reach down and bring her baby to her.?

Regardless of where in the world this happens, the sacred moment of guiding and empowering an individual safely through the journey of pregnancy and birth is universal. At Seed Global Health, our efforts are focused on improving maternal and newborn care?in sub-Saharan Africa – where the greatest burden of morbidity and mortality exists.?

However, on Mother’s Day, we cannot ignore what is happening in our own backyard. Maternal mortality is rising, leaving the U.S. with the?worst maternal mortality rate of developed nations. Unacceptable disparities in maternal health outcomes by race and ethnicity mean that black mothers are dying at?3-4 times the rate?of white mothers. And there?are vast areas of this country with very limited or no access to obstetric care, which affects up to 6.9 million women and almost 500,000 births (March of Dimes, 2022).?

Everyone should be asking why we do not have more midwives to address this maternal health crisis. Currently, midwives only?attend 11%?of all births in this?country.

Why midwives? More and more data is coming out proving that the midwifery model of care and midwives are?cost-effective, have excellent patient satisfaction, low rates of intervention, and improved maternal health outcomes (The Lancet, 2014).?

Midwives, as members of an integrated healthcare system, can deliver?approximately 90%?of essential sexual, reproductive, maternal, newborn, and adolescent health needs across the life course.?

A rigorous study looked at the potential impact of scaling up midwifery and found that if efforts were made to achieve universal coverage of midwife-delivered care, 50% of maternal deaths in medium to high income countries, like the U.S., could be averted (The Lancet, 2021). Globally, this could?result in?280,000 fewer deaths in mothers, 2 million fewer deaths in newborns, and more than 2 million fewer stillbirths per year by 2035.

If we could increase the number of births performed by midwives to 20% over the next 6 years—closer to what we see in other developed nations—it would generate nearly $3 billion in savings for private insurers and?over $1 billion?in savings for state Medicaid plans in addition to lives saved.?

Given all these findings, the Biden Administration in their White House Blueprint for Addressing Maternal Health Crisis, has called for an increase in midwives, noting that midwives are critical missing components of the maternal health care workforce (White House, 2022).?The World Health Organization has done the same, recommending that midwifery care should be?substantially increased?to reduce maternal mortality in every country regardless of the state of their health care system.?

Despite all this evidence and all these recommendations, why is the U.S. not investing in midwives?

Many people have a misunderstanding of the role of midwives in maternal and obstetric care. Some believe that midwives are not safe, or that they are never covered by insurance. Others think that midwives only assist people with home births and do not practice in hospitals or do not offer pain relief options in labor, such as epidurals. None of this is true. For pregnant individuals, midwives can offer most of the same care that any physician trained in obstetrics can offer, excluding a cesarean or vacuum assisted delivery. In cases that do become medically complicated, midwives work in collaboration with physicians who can provide this added layer of care if necessary.??

Another reason some individuals don’t understand midwives: pregnancy and birth in the U.S. has become over-medicalized with increasing rates of cesareans and inductions of labor to the point that pregnant individuals perceive pregnancy and birth as inherently dangerous. This is not true. Only a small percentage of pregnancies and births are medically complicated. The majority are physiologically normal and uncomplicated.?

Another issue hindering the expansion of midwifery is reimbursement. Depending on the state, Medicaid and many private insurance companies only reimburse facilities?75% to 90%?of the cost for a vaginal birth performed by a midwife. Some, but very few, reimburse 100%.

Therefore, if a vaginal birth costs a hospital $10,000, the insurance company reimburses the hospital $8,000 if a midwife performs the birth, versus the full $10,000 if a physician performs the birth. If a hospital does 3,000 vaginal births a year and the majority of vaginal births are performed by midwives rather than doctors, the hospital could potentially lose $6 million in revenue. Therefore, what financial incentive does a hospital have to employ midwives? We would argue very little.?

What needs to be done? Midwifery needs a rebranding. Individuals of reproductive age, public health colleagues, and the midwifery community must work together to show the public who midwives are, what they do, and how they provide evidenced-based care with excellent maternal and newborn health outcomes.

Also, we need to press politicians to pass legislation requiring Medicaid and private insurance companies to reimburse midwives equally to their physician colleagues for performing the same medical services, such a vaginal birth. In doing so, there will be greater financial incentive for hospitals to support and expand the midwifery workforce.

The statistics say it all: the current health care system is not adequately caring for our pregnant individuals and their babies. We must make some changes. The evidence is clear and the mandate across governing bodies is clear: We need more midwives.??

Dr. Vanessa Kerry, CEO, Seed Global Health

Julie Mann, Associate Director of Midwifery, Seed Global Health