Maternity care in the United States is in crisis. It’s time to call the midwife

AAfter pushing for several hours, my patient looks exhausted but happy, clutching her seconds-long newborn to her chest. As I help her put her baby to the breast for the first time, she thinks of nothing but the little human looking up at her.

She shouldn’t either.

Little does she know that this birth would have taken place by C-section in most US hospitals, which would have exposed her to a multitude of complications and virtually guaranteed that any future births would also be by C-section. But I do.

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As a certified nurse midwife, I know that my presence, patience, and encouragement during her labor probably made the difference between a vaginal birth and a C-section. A recent study linked midwifery care from hospital-based midwives like me to 30-40% lower rates of caesarean sections in low-risk women.

In the United States, approximately 32% of births occur by caesarean section, although the World Health Organization recommends higher rates not exceed 10% to 15% for optimal maternal and neonatal outcomes. But cesarean section rates aren’t the only area where the United States is underperforming.

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To 24 deaths per 100,000 live birthsits maternal mortality rate is closer to that of Iran than economic peers like UK or Germany. Prematurity, a major cause of infant mortality and lifelong disability, occurs 1 in 10 births. Seven million women live in maternity deserts with minimal access to care. Yet, with the average cost of maternity care in nearly $19,000the United States spends significantly more on maternity care than countries with much better outcomes.

The reasons for expensive and poor-quality maternity care in the United States are complex. But a rarely recognized difference between the United States and countries with better results is that they use more midwives. The United States has a similar number of OB-GYNs per 1,000 births compared to countries like Britain, the Netherlands, and France. But in these countries, midwives are an integral part of the health care system, outnumbering OB-GYNs 3 to 1.

Why does this model work? A strong midwifery workforce frees up doctors to focus on high-risk pregnancies while providing low-risk pregnant women with more personalized care with longer visits and increased psychosocial support, which are typical of model of midwifery care.

Just as midwifery has succeeded abroad, US states with greater integration of midwives in their health care systems have better outcomes, including lower rates of caesarean sections, preterm births and neonatal deaths.

So why is the US sitting on a solution that could clearly benefit childbearing families? A multitude of cultural and historical reasons explain the continued marginalization of midwives in the United States

I sometimes envy my colleagues across the Atlantic, where “midwife” is a household name that commands respect and admiration. Midwifery is widely accepted by the UK public and medical system, with 43 midwives per 1,000 births compared to 4 per 1,000 in the US. It barely made headlines when Duchess Kate Middleton delivered her babies with midwives. Instead, The Economist thought giving birth to Kate in a private luxury maternity suite was cheaper than the average vaginal birth in the USA.

In the United States, midwives like me face a different reality. I’m often asked to explain the difference between a midwife – a licensed health care provider – and a doula – a counselor who provides emotional support and guidance throughout the childbearing process. I have to defend my education and credentials to people who assume I have no formal training, although becoming a certified nurse midwife requires a master’s degree, hundreds of hours of clinical training and board certification.

Midwifery is often viewed by the American public as a marginal choice for women who avoid pain medication during labor and plan to give birth at home. While it is true that most home births are attended by midwives – usually certified professional midwives, who have extensive apprenticeship training – the the vast majority of births attended by a midwife take place in hospitals, with certified nurse midwives like me. And women don’t have to choose between a midwife and an epidural. I’ve seen births of people who labored in a tub with aromatherapy and soft music in the background, and those who had epidurals and watched the Green Bay Packers game.

The public relations problems of American midwifery are deeply rooted in history. A American Medical Association campaign in the early 1900s discredited midwives as charlatans. Doctors lobbied to scrap midwifery training programs and pass laws making midwifery illegal. Joseph DeLee, an influential early 20th century obstetrician, called midwives the “relic of barbarism”. Sexist and racist attacks painted midwives as dirty, uneducated and dangerous. By the 1940s, the practice of midwifery was virtually eradicated in the United States.

It was, however, preserved in black communities, whose members were not allowed in many hospitals during segregation. The African-American midwife Margaret Charles Smithwhose career attending home births in Alabama spanned decades, wrote in his autobiography about black patients who were denied access to hospital even when they had life-threatening complications. Ironically, she was later banned from attending home births after it was made illegal. Highly trained midwives like Smith have been forced out of business, leaving black communities without their traditional caregivers.

Discrimination against midwives is still entrenched in health care policy. This limits the number of midwives and hampers the efforts of existing midwives.

Midwifery education programs are few and underfunded, receiving only a fraction of the funding that medical schools and residency programs receive. Universities offering midwifery programs rely primarily on volunteer midwives to train students in in-person clinical work without reimbursement, thus limiting the supply of volunteer preceptors.

Recent interest in increasing the training capacity of midwives has led to the Midwifery Act for Moms, which was introduced to Congress in 2021. It would provide funding to create or expand education programs with a focus on restoring midwifery practice to underserved areas. Passage of this bill is essential if the United States is to begin to address its shortage of midwives.

In my country of origin and many others, a midwife’s ability to practice legally depends on a physician’s willingness to sign a collaborative agreement. An obvious trade restriction, laws like this give doctors the ability to intentionally exclude midwives from the workforce due to competition concerns. They also create burdensome requirements and potential liability for physicians who would otherwise be willing to work with midwives, which discourages collaboration.

Overcoming decades of prejudice against midwifery will not be easy, but I see a tipping point on the horizon. At 1 in 10, the number of births attended by a midwife in the United States is the highest in decades. Women are increasingly choosing midwives, putting pressure on health systems to meet demand by hiring more. Healthcare administrators may also notice that, at $116,892 compared to $302,301the annual cost of employing a certified nurse midwife is significantly less than employing an OB-GYN.

Midwifery care reduces costs, improves outcomes and increases patient satisfaction. The next logical step is to create policies that increase the number of midwives and address barriers to midwifery practice.

I would like to live in a country where my profession is better understood and more respected. But it’s really not about me. The United States needs more midwives because the country’s below-average birth outcomes and excessive costs are proof that pregnant women aren’t getting the care they need most while dollars health care is wasted.

The country has already waited too long: it is time to call the midwife.

Ann Ledbetter is a certified nurse-midwife at Sixteenth Street Community Health Centers in Milwaukee, Wisconsin, and a member of the Wisconsin Maternal Mortality Review Team.

About Antoine L. Cassell

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