Integrating midwifery model of care key to address disparities, maternity care crisis

Key takeaways:

• The U.S. has four midwives for every 1,000 live births vs. 30 to 70 midwives in other high-income countries.
• Midwifery integration was linked to lower rates of race-specific neonatal mortality.

More fully integrating the midwifery model of care in philosophically aligned health care teams and institutions could be important in addressing disparities and the maternity care crisis in the U.S., according to a published expert review.

“Birth is a crucial transitional event in the continuum of pregnancy and parenting. This time often draws the most concern from parents and providers alike and can have lifelong effects on the childbearing person and their family,” Joan L. Combellick, PhD, MPH, MSN, CNM, assistant professor in nursing and interim nurse-midwifery specialty co-director at Yale University School of Nursing, and colleagues wrote. “However, birth does not occur in isolation. What happens during this time is influenced by the individual’s physical and mental health, history and demographic characteristics, prenatal period and sociocultural context of the pregnancy. Furthermore, it is greatly influenced by health care providers, care protocols and the physical environment in which care is received.”

In an expert review, published in the American Journal of Obstetrics & Gynecology, the authors described midwifery practice emphasizing the intrapartum setting; discussed the role of midwifery in team-based care, collaborative practice and teaching; reviewed midwifery and birth settings; and assessed evidence for midwifery care in an international context and in the U.S.

Midwifery care in the U.S.

In the U.S., there are four midwives and 11 obstetricians for every 1,000 live births compared with 30 to 70 midwives for every 1,000 live births among most other high-income countries, the authors noted. In addition, educational preparation and licensure for midwives in the U.S. vary.

The U.S. had a higher maternal mortality ratio of 17 deaths per 100,000 live births in 2017 compared with 10 deaths per 100,000 live births or lower among other high-income countries. In 2020, of 3,613,647 births, the U.S. had 3.5 deaths per 1,000 live births, which was the highest neonatal mortality rate, and midwives attended 10% of births. The authors highlighted that expanding the midwifery workforce is a key strategy to improve maternal and neonatal outcomes in the U.S.

Prior research found that higher midwifery integration scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean delivery and breastfeeding, and use of midwives was also associated with significantly lower rates of cesarean delivery, preterm birth, low birth weight infants and neonatal death. Researchers also found lower rates of race-specific neonatal mortality with higher midwifery integration, suggesting that greater midwifery integration in health care may improve health benefits for Black infants.

Among studies analyzing the association between U.S. medical centers with and without midwives on the maternity care team, low-risk nulliparous women who gave birth at centers with midwives were 74% less likely to have induced labor, 75% less likely to receive oxytocin augmentation and 12% less likely to deliver via cesarean section compared with counterparts at centers without midwives.

Results were similar for low-risk parous women, with those who gave birth in centers with midwives 85% less likely to have induced labor, 36% less likely to deliver via cesarean section and 31% more likely to have a successful vaginal birth after cesarean delivery compared with counterparts at centers without midwives.

Challenges to midwifery in the U.S.

Many barriers to midwifery care are present in the U.S., including racial and ethnic disparities, lack of maternity care providers, philosophical misalignment and medicalization of labor and birth. Addressing these barriers may improve overall midwifery care in the U.S., the authors wrote.

In a CDC report on maternal mortality rates in the U.S. in 2020, results showed that the maternal mortality rate for non-Hispanic Black women was 2.9 times higher compared with the rate for non-Hispanic white women (55.3 vs. 19.1 deaths per 100,000 live births). During COVID-19, the authors noted, maternal mortality significantly increased among non-Hispanic Black and Hispanic women, but not for non-Hispanic white women. Previous studies found that hospital birth, feeling pressured to have interventions and having an instrumental birth are factors that contribute to low-quality care experiences, according to the authors. Women with midwives had a greater than three times higher likelihood for high-quality perinatal care. Also, continuity of care with a known midwife resulted in reduced fear and perception of labor pain and increased perceived control, information and participation in decision-making.

More than half of U.S. counties lack a maternity care provider, the authors wrote, which leaves women without proper access to care. Midwives are also more likely to serve populations at risk for poor pregnancy outcomes due to demographics or social determinants of health. Previous surveys found that 50% of U.S. midwives reported serving people of color, 29% cared for adolescents, 27% cared for immigrants and 16% cared for uninsured women.

Midwife burnout can also be high when they practice in environments without support of the midwifery model of care. In addition, maternity care teams may not share the same care approach and staffing ratios might limit the ability to provide optimal person-centered care. According to the authors, it is also possible that intrapartum settings may not incorporate models where the childbearing family knows their provider well and is supported in decision-making.

The trend moving toward the medicalization of labor and birth also creates challenges to midwives educated to minimize interventions unless required. Since 2018, there has been an increasing trend toward labor induction.

Recommendations for the future

Given these findings, the authors suggested examining why women choose to give birth at home and whether they do not believe they will receive their required care in a hospital setting. The authors recommended that health care systems reevaluate how they provide care and whether they are meeting families’ needs. The authors also noted that the safety net for women giving birth at home should be improved to develop ways for robust collaborations with obstetricians and facilitate seamless transfers to a higher level of care, if needed.

Currently, Australia, Canada, the Netherlands and the United Kingdom are the four countries in the world with low rates of maternal mortality, birth weight and newborn and infant mortality. These countries identified the following five common factors:

• affordable and accessible health care;
• emphasizing midwifery care and interprofessional collaboration;
• respectful care and maternal autonomy;
• evidence-based guidelines on place of birth; and
• national data collection systems.

The authors recommend that health care systems assess their ability to provide respectful care to ensure freedom from harm, informed choice, continuous support, effective communication and midwife-led continuity models. The authors also endorse recommendations from the “Blueprint for Addressing the Maternal Health Crisis” released by the White House in June 2022 that include the following priorities:

• increase access and coverage of comprehensive high-quality maternal health services;
• ensure women who give birth are heard and are decision-makers in accountable systems of care;
• advance data collection, standardization, harmonization, transparency and research;
• expand and diversify the perinatal workforce; and
• strengthen economic and social supports for women before, during and after pregnancy.

“Expanding the midwifery model of care would align the United States with peer nations that consistently demonstrate maternal and neonatal outcomes that are significantly better than those found in the United States,” the authors wrote.