How Expanding Access to Midwifery Care Can Help Us Address the Maternal Health Crisis
Where We Are: The Maternal Mortality Crisis
Both maternal and infant mortality is on the rise in the United States. The National Center for Health Statistics recently released a report detailing how infant mortality has risen for the first time in the last two decades. Additionally, the American Medical Association has reported that maternal deaths (deaths resulting from a live birth) in 2019 nearly doubled that of the rate in 1999. The Massachusetts Department of Public Health reported that between 2011 and 2021, severe maternal morbidity nearly doubled, with the highest rates of delivery complications being concentrated among Black patients.
These breathtaking statistics become even more sinister upon closer inspection. Black, Native American, and Alaskan Native mothers continue to have the highest rate of pregnancy complications, and a significantly lower infant survival rate than white populations. Systemic inequities in modern institutional medicine contribute to an ever-growing divide in outcomes for white families compared to families of color. Historically, physicians have often failed to take complaints of pain from pregnant patients who are non-white seriously, or have failed to effectively communicate certain risks arising from pregnancy and precautions one might take to that same group of patients, leading to higher levels of devastating outcomes.
While the medical community works to address this systemic racism, we can also supplement this care divide with supportive care that is patient-centered and part of a rich historical tradition. Enter the midwife.
What is a Midwife?
Midwives are certified health care professionals who work, often in tandem with both physicians, nurses, and doulas, to support health pregnancy outcomes. According to the American Pregnancy Association, midwives can provide “an array of health care services for women including gynecological examinations, contraceptive counseling, prescriptions, and labor and delivery care.”
Midwives often offer a more supportive and holistic approach to care that centers the patient and their needs, and acknowledges that birth can be an extremely challenging emotional, mental, and spiritual existence. While also being able to provide rigorous vital monitoring for heart rate and blood pressure, midwives are specifically trained to provide emotional and mental support to new parents, and help guide them through the steps of pregnancy, birth, and postpartum/early infant care. This can help reduce the overall stress of birth and streamline the process into one leading advocate for a patient who can assess their medical needs and provide critical coaching and emotional support.
Different types of midwives give patients the option for in-hospital and out-of-hospital care. Your birthing experience can be catered to you. With the opening of more birthing centers and the wider certification and availability of midwives, more and more patients are able to choose the birthing experience that is right for them.
The History of Midwives
Midwives have been around since long before the written historical record. Midwives are referenced in many ancient historical texts and accounts of antiquity, and have continued to be a source of support, advocacy, and knowledge for pregnant patients during labor. There is a storied history of colonial midwifery, and subsequent racist bans that reduced the ubiquity of the practice in the United States, leading to a growing racial divide in maternal health outcomes.
Of midwifery in the colonial era, legal scholar Michele Goodwin writes, “Midwifery was interracial; half of the women who provided reproductive health care were Black women. Other midwives were Indigenous and white.” Midwifery practice was an opportunity for employment for Black women in the Reconstruction era, although this opportunity quickly led to racial retrenchment and the forced obsolescence and criminalization of traditional/non-medicalized birth practices. Under the guise of scientific advancement, this rejection of midwifery care was used as a means to exclude Black and Brown women from the workforce (and from delivering white babies).
With advancements in medicalization at the onset of the 19th century and the burgeoning popularity of the medical reform movement leading to more strict licensure for physicians, midwives were viewed by their white male physician counterparts as part of a pseudoscientific class of support staff, and systematically eliminated from the formal health care apparatus. At the time, the reason given was that because midwives were less easy to certify (due to the knowledge of midwifery often being handed down generationally through women, as opposed to the process of formal instruction in a school), there may be disparities in care between high- and low-quality midwives. Of course, this concern for class disparity was race-singular: white physicians did not care if poor Black mothers were accessing what they deemed as “lesser” health care, but saw the criminalization of midwives as another opportunity to curb Black population growth by ensuring Black mothers had neither the option of a midwife, nor a physician when it was time to deliver a baby.
These historical racial siloings of health care persist today in the form of health care deserts, systemic-racism-induced generational health problems, the reproduction of racial poverty, and more, culminating in a significantly higher maternal mortality rate for Black mothers than white mothers. Additionally, white doctors saw midwife bans as an opportunity to excise Black female laborers from the workforce by eliminating one of their most popular professions, and one that they had the unique ability and training to perform.
Midwife bans and policies have extremely racist origins – which is part of the reason why supporting the advancement and proliferation of midwifery care can help reduce the racist divide in maternal mortality outcomes.
How Can Midwives Help Ameliorate the Maternal Mortality Crisis?
Midwives can help reduce the maternal mortality crisis and lessen the racial disparity in maternal health outcomes in a few key ways:
Providing holistic, patient-centered care that accounts for the emotional, physical, and spiritual wellbeing of the pregnant person. Because midwives are trained to meet the full need of a pregnant patient – whether that is their formal medical needs such as monitoring for blood pressure changes, heart health, other vital signs, ensuring the actual process of birth is running smoothly, or making sure the patient has ample emotional support during the process of birth – they can ensure patients receive the care they need in the often traumatizing process of childbirth. Birth is an extreme strain on the body and a radical feat of nature, and needs critical and highly specialized care and supervision. Midwives can do that, and can utilize their deep knowledge of the birthing process to help usher patients along with grace and ease.
Decreasing strain on the health care system caused by a widespread OB/GYN provider shortage and allowing patients more options for care with wider availability. A huge contributor to the maternal mortality crisis is the widespread lack of providers. With the provider shortage particularly increasing post-Dobbs due to concerns in the field of medicine over the safety of practicing obstetrics and gynecology, the issue of patient access to care will only increase. Certifying and supporting midwives can help ensure every patient has access to the care they need when they need it.
Advocating for patients within the formal health care system to ensure they are getting high-quality, consistent care. Particularly for patients of color, patients could often use an advocate when interacting with the health care system. Because midwives have tons of expert knowledge and experience, they can advocate for patients they support during pregnancy, childbirth, and postpartum care to ensure patients get equitable, consistent, high-quality care.
Allowing patients more flexibility and freedom with where and how they deliver. Certified Professional Midwives are especially trained to attend births in places that are not hospitals; they can deliver babies in birthing centers, private practices, and even at home. For some patients, choosing to birth in a setting that is not a hospital is the best choice. Reducing the medicalization of birth can be highly preferable to a patient, and patient autonomy is a human right. Pregnant people deserve to choose where they give birth.
Here’s Where We Come in:
A slate of legislation is being considered by the Massachusetts legislature now to support birth justice in the Commonwealth and support midwives.
Reproductive Equity Now strongly supports passage of:
An Act promoting access to midwifery care and out-of-hospital birth options (H.2209/S.1457), sponsored by Sen. Becca Rausch, Rep. Kay Khan, and Rep. Brandy Fluker Oakley, creates a pathway to licensure for certified professional midwives and makes their care reimbursable by Medicaid/MassHealth
An Act updating the regulations governing licensed birth centers in Massachusetts (H.3616/S.1335), sponsored by Sen. Jo Comerford, Rep. Manny Cruz, and Rep. Chynah Tyler, addresses onerous and outdated barriers to the creation of free-standing birth centers
An Act to increase access to nurse-midwifery services (H.1069/S.607), sponsored by Rep. Kay Khan and Sen. Brendan Crighton ensures equitable insurance reimbursement parity for certified nurse midwives
An Act relative to birthing justice in the Commonwealth (S.1415), sponsored by Sen. Liz Miranda, includes language from the above-referenced midwifery and birth center bills as well as additional urgently-needed policies for optimal maternity care and to address long standing racial inequities in maternal health care
