The United States has the highest maternal mortality rate among developed countries and our intervention-based biomedical system is largely to blame (Hoyert, 2019). How can the United States significantly decrease this maternal mortality rate? Is it possible for our biomedical system to finally take a holistic approach to pregnancy in our hospitals? According to one study, the presence of midwives in hospitals leads to a significant decrease in preterm birth, surgical intervention and use of analgesic during pregnancy, as well as an increase in overall satisfaction of childbirth among women (Sandall et al., 2016). Despite carrying the burden of a high maternal mortality rate, the American medical system has yet to incorporate the help of midwifery into our hospitals on a large scale.
The approach of the midwifery model of health care has the potential to work alongside our current medical system as well as crucially improve it. For most pregnant women in the United States, the primary care provider during pregnancy is an obstetrician. Due to the hasty pace of most hospitals in America, pregnant women often do not receive the quality care that they should. However, a midwife is a trained professional that takes a holistic approach to pregnancy care, often treating pregnant women throughout pregnancy during labor, delivery, and even postpartum. A research study was conducted with 126 hospitals in New York. Out of those 126 hospitals, thirty-three had no midwife-attended births, fifty-five had 15% of births attended by a midwife, twenty-two hospitals had more than 15% attended by a midwife, and sixteen hospitals had more than 40% attended by a midwife (Attanasio and Kozhimannil, 2017). The research study concludes that the presence of more midwives in hospitals has decreased the rates of labor induction, cesarean birth, and maternal morbidity rates. Even with the large amount of evidence in the past ten years on the effectiveness of midwives in hospitals, the number of midwives in our hospitals is not nearly where it needs to be.
In addition to the effect that midwives have on maternal mortality rates in America, midwives also enhance the overall experience of childbirth for many women which is an equally important topic. Often, physicians will aim their focus towards the newborn during labor and delivery instead of the woman. A study to assess women’s experience of childbirth, including components such as pain intensity, anxiety during labor, and feeling proud of themself, showed that women receiving midwifery care during labor and delivery were more likely to rate their childbirth experience as more positive overall than women who did not have a midwife present (Sandall et al., 2016). This leads to high dissatisfaction outcomes for many American women across America during and after childbirth. Compared to other industrialized countries, access to midwifery care in hospitals in the United States is significantly lower; approximately 10% of US births are attended by midwives as compared to 50–75% in other industrialized countries (Saraswathi et al., 2018). In other countries such as France, Switzerland and Germany, the implementation of midwives alongside other medical care professionals, such as nurses and doctors, is a common service for reproductive, maternal, and neonatal health (Richter, 2020). In order to provide the best healthcare for pregnant women and to bring a holistic view of labor and delivery, health care professionals should be working together to decrease maternal mortality rates as well as surgical interventions. Additionally, a study conducted by the NIH contrasted women who gave birth at interprofessional medical centers (midwives and physicians) versus non-interprofessional medical centers. The results showed that women at interprofessional centers were 74% less likely to undergo labor induction. The cesarean birth rate was also 12% lower at these interprofessional centers (Neal et al., 2019).
Currently, we do not have any national funding regarding maternal and newborn health that incorporates the aid of midwifery into the healthcare system. Within a hospital, midwives are typically funded by insurance; usually this indicates that the midwifery practice is affiliated with that hospital (Dellos, 2017). However, the amount of insurance that covers midwifery care in hospitals varies by insurance type and the state you are in. According to the American College of Nurse Midwives (2014), 20% of insurance plans do not contract with Certified Nurse Midwives (CNM) and 17% do not fully cover primary care services by CNMs. As mentioned earlier, in France, implementation of midwives alongside other medical care professionals is a common service for maternal care. Compared to the United States where funding of midwives varies by the state, funding for midwifery care in France is defined at the national level by the Ministry of Social Affairs, Health, and Women’s Rights and statutory health insurance (SHI) funds which are grouped under the National Union of Health Insurance Funds. If midwives were to be 75–100% covered by insurance across all 50 states, the use of midwives in hospitals has the potential to increase significantly and thus reduce the maternal mortality rate in the United States (Hoope-Bender et al., 2014). Adjustments towards effective coverage of midwives in America would aid other healthcare providers in navigating heavy workloads in hospitals and increase the productivity of midwives and their care for pregnant women (Hoope-Bender et al., 2014).
Many patients may be reluctant to accept midwifery into their hospital labor and delivery care because of the different education that is required to become a midwife. To become a certified nurse midwife, individuals must earn a master’s degree in nursing accredited by the Accreditation Commission for Midwifery Education. In some states, CNMs can work independently with their patients; however, patients may be more likely to accept an obstetrician over a nurse midwife for care. Expecting mothers may choose an obstetrician over a midwife because of common myths in the medical field such as “midwives cannot prescribe and administer pain medications” (UnityPoint Health, 2014). However, this is untrue and midwives are certified and capable of giving pain medications during birth. Another reason why mothers may choose an obstetrician is in the case of a high-risk emergency during the birth, midwives are not trained to do surgery by themselves (UnityPoint Health, 2014). However, midwives are able to assist in the surgery and provide support every step of the way. Thus, doctors that have to go through 8 years of training to become certified physicians may be more likely to be accepted by a patient as the primary care professional during pregnancy.
In short, the incorporation of midwifery care provides a new and holistic approach to care during pregnancy and childbirth. The significant impact of midwives on maternal mortality rates, surgical intervention during labor, delivery, and the overall childbirth satisfaction is too great to ignore. In the near future, I hope to see funding of midwifery care in the US at the national level rather than funding by state so that midwifery care is accessible to all mothers. Additionally, an increase in the number of midwives on our medical health care teams is needed for the overall satisfaction of birth among mothers and decrease in mortality rates in the United States. Our common goal should be to decrease maternal mortality and surgical intervention rates during childbirth, and midwives can help us do just that.
Attanasio, L., & Kozhimannil, K.B (2018). “Relationship Between Hospital-Level Percentage of Midwife-Attended Births and Obstetric Procedure Utilization.” Journal of Midwifery & Women’s Health, 63(1), 14–22.
Hoope-Bender, P. T., Bernis, L. D., Campbell, J., Downe, S., Fauveau, V., Fogstad, H., … & Lerberghe, W. V. (2014). Improvement of maternal and newborn health through midwifery. The Lancet, 384(9949), 1226–1235.
Hospital, U. H. (2014). Choosing Between an OB/GYN and a Midwife. Unity Point Health.
Jordan, A. (2021). How to Become a Nurse Midwife: Nursing Careers. ProvoCollege.
University of Iowa Hospitals & (2018). Midwifery Myth: Health Insurance Does Not Cover Midwife Care. Clinics.
Hoyert D.L. (2019). Maternal mortality rates in the United States. NCHS Health E-Stats.
Richter, F. (2020). Infographic: U.S. Midwife Workforce Far Behind Globally.
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2015). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews.
Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. A. (n.d.). France.
Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, R., Cheyney, M., Fisher, T., Butt, E., Yang, Y.T., Kennedy, H.P. (2018). Mapping Integration of Midwives across the United States: Impact on Access, Equity, and Outcomes. PloS One, Public Library of Science
Neal, J. Jeremy, et al. (2019). Midwifery Presence in United States Medical Centers and Labor Care and Birth Outcomes Among Low-risk Nulliparous Women: A Consortium on Safe Labor Study. Birth, 46(3), 475–486.