Midwives in Medicine

Over the last several decades, maternal mortality has steadily increased in the US. The rate of maternal death from pregnancy-related causes has more than doubled since 1987 from 7 per 100,000 births to 19 in 2017. The risk of death is even worse among Black women who are 3-4 times more likely to die during or after childbirth than White women.  And for every death, up to 100 women will experience severe injuries as a result of pregnancy-related conditions like high blood pressure or blood clotting disorders.

Most of these events are preventable, but shortages of maternity care in the US have reached critical levels. The number of hospitals offering obstetric-gynecological care has fallen more than 16% since 2004, particularly in rural areas. The quality of maternal care in the US is often poor. Once a baby is born, mothers are monitored less frequently. Their concerns are often dismissed, and they tend to be sent home with inadequate information about potentially concerning symptoms.

One way to improve maternal health outcomes may be to incorporate midwifery services into maternal care. Midwifery is “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, pregnancy, birth, post-partum, and the early weeks of life.” Midwifery goes beyond the scope of standard obstetric and gynecologic care, incorporating detailed care plans developed according to mothers’ unique, personal needs, and circumstances.

But midwifery is commonly misunderstood. Midwifery practice dates back to the beginning of human history. Through the 19^th century, midwives attended most births in America, but with the advent of modern medicine, women were often discouraged to use midwives during childbirth. Now, midwifery practice is reemerging as more than an option for women who prefer a natural birth. Midwives are sought for their unique model of maternal care.

For many women, midwifery services are relatively inaccessible–they’re often too expensive and not covered by insurance.

The Massachusetts legislature is currently considering a bill that aims to improve access and affordability of midwifery services, but there is debate around whether the bill would accomplish these goals. H.1948, An Act Relative to Out-of-Hospital Birth Access and Safety would require midwives to become licensed in order to provide midwifery services to pregnant women. The law would establish a board of registration in midwifery consisting of experienced midwives, a physician, a certified nurse-midwife (CNM), and a member of the public. The board would be charged with the task of developing regulations around licensure qualifications, fees, and other requirements.

Today in Massachusetts, there is no process or requirement for midwives to become licensed. Some midwives argue the added administrative and financial burden associated with state licensing requirements disincentivizes pursuing midwifery as a career and could mean that fewer women choose to become midwives. Others believe that licensing is the best way to integrate midwives into standard obstetric care and improve the quality of maternal and newborn care.

A key element of the legislation is that it would encourage physicians to work with midwives and thereby improve the chances of midwifery services being covered by insurance.

Research suggests states in the US that have integrated midwifery services into obstetric and gynecologic care through legislative reform have better birth outcomes—fewer maternal deaths—than states that do not. When midwives are fully integrated, they’re able to work as part of an interprofessional team. In states without licensure requirements for midwives, doctors and hospitals are often reticent to work with midwives for fear of liability if something goes wrong.

For many women, midwifery services are relatively inaccessible–they’re often too expensive and not covered by insurance. Those in support of H.1948 believe licensing requirements would standardize the training midwives receive and make it easier for those seeking a midwife to evaluate potential midwives. Many proponents are also hoping the bill would include an amendment ensuring midwifery services are covered by Massachusetts’ Medicaid program. Supporters argue this would make it much easier for women–and particularly women of color–to receive the high quality care midwives provide.

The bill has not yet been scheduled for a vote.

Photo by Fé Ngô on Unsplash