Why Midwife-Led Care?

Increasing access to  the midwifery model of care can lead to better outcomes, a reduction in racism-based disparities, and increased access to care.

Problem: Maternal Mortality and Morbidity Crisis

The United States is a clear outlier among high-income countries, with a maternal mortality rate that far exceeds even the other worst performing high-income countries. 

When you disaggregate the data to show the impact of racism-based disparities, Black women are dying at 3-4 times the rate of white women. 

However, lack of exposure to racism is not fully protective against maternal mortality in the United States. Even the maternal mortality rate for white women is much higher than the closest worst-performing, high-income country.

Maternal mortality is just the tip of the iceberg and is representative of poor outcomes on a number of axes related to maternal and infant morbidity. 

Chart source: Gunja MZ, Gumas ED; Williams II RD (2022) The U.S. Maternal Mortality Crisis Continues to Worsen: An International Comparison. The Commonwealth Fund.

Of note, in the Netherlands, one of the countries where maternal mortality rates have dropped in recent years, there was an increase in home births and vaginal deliveries, and a decrease in cesarean sections (both planned and emergency) during the pandemic. These changes may have contributed to the lowering maternal deaths during this time.

The midwifery model of care is standard in all countries that have better birth outcomes.

Solution: Midwifery Care improves outcomes 

LESS Likely With Midwifery Care:

  • Cesarean birth

  • Operative Vaginal Delivery

  • Induction of Labor

  • Episiotomy 

  • Perineal Lacerations 

  • Use of Pain Medicine

  • Epidural Anesthesia

  • Continuous Fetal Monitoring 

  • NICU admissions

  • Preterm birth and low birth weight infants

  • Fewer infant emergency department visits and hospitalizations

  • Neonatal Deaths

MORE Likely With Midwifery Care:

  • Spontaneous Vaginal Birth

  • Labor After C-Section (TOLAC)

  • Vaginal Birth After C-Section (VBAC)

  • Breast Feeding 

  • Patient Confidence & Control

  • Patient-Centered Care

  • Lower Costs 

Research by Birth Place Lab finds that overall integration of midwives into maternity care in the United States is correlated with improved outcomes.

CMS research found that Medicaid Recipients who received maternity care through birth centers (aka the Community midwifery model of care) had better outcomes relative to Maternity Care Home participants after controlling for demographic, medical, and social risks.

Birth Place Lab also found poor integration of midwives in states with the highest rates of Black births and the highest rates of neonatal mortality. Their analysis shows that race accounts for 35% of the difference in neonatal deaths, and integration of midwives accounts for almost 12% of the difference. Improving access to and integration of midwives in these states could have powerful positive benefits for African American families.

Best Start Key Takeaways: "Women receiving prenatal care in birth centers participating in the Strong Start study had better birth outcomes and lower costs than similar Medicaid beneficiaries not enrolled in the study. In particular, rates of preterm birth, low birthweight, and cesarean section were lower among birth center participants, and costs were more than $2,000 lower per mother-infant pair during birth and the following year. These promising birth center results may be useful to state Medicaid programs seeking to improve the health outcomes of their covered populations. 

Source: Strong Start for Mothers and Newborns Evaluation of Full Performance Period (2018)

An abundance of research supports improved outcomes with primary midwifery care.

As reported in the New York Times, this study of births in California found that “the richest Black mothers and their babies are twice as likely to die as the richest white mothers and their babies”. While California has made great strides in reducing maternal mortality, racism-based disparities persist.  

Article source: The New York Times.

Problem: Racism-Based Disparities

Solution: Midwifery is a Key Intervention To Reduce Racism Based Disparities 

Black maternal health leaders identify access to midwife-led care as a key intervention to help reduce racism-based disparities

The California Black Birth Justice Agenda: Unifying the Vision for Systemic Change 2023

Recommendations incude:

“We encourage state legislators, Medi-Cal, and private health insurance plans to facilitate the coverage of community birth, so Black women and birthing people have more options for high quality maternal care. Medi-Cal and private health insurance plans should increase their reimbursement rate for birth center and midwifery care. This would incentivize birth centers to accept patients with Medi-Cal and private health insurance, and it would strengthen essential services provided by midwives.”

Black Mamas Matter In Policy and Practice (2023)   

Recommendations include:

  • Expand midwifery licensure and access

  • Increase access to birth centers 

  • Develop home birth infrastructure

Battling Over Birth: Black Women & The Maternal Health Care Crisis in California 

Black women identify increased access to the midwifery care as one of the key interventions to solving the Black maternal and infant mortality and morbidity health crisis in California 

BIPOC people in California indicate an unmet desire for midwifery care

California Health Care Foundation Listening to Mother’s in California (2018) found that women of all races and insurance types expressed desire for midwifery care that exceeded access to midwifery care. Access to midwives was most accessible to white and privately insured individuals. Midwives were least accessible to Black people and people insured by Medi-Cal.

Problem: Californians lack Access to Sexual and Reproductive Health Care Providers

Maternity Care Deserts

Nine counties in California have no OB/GYN at all and 19 counties have 5 or fewer OB-GYNs. As of 2019, 19 counties have 5 or fewer OB-GYNs. There has been no increase in the number of OB-GYNs trained since 1980 despite a projected increase of 22% in California’s female population by 2030.

Source: March of Dimes.

Solution: Midwives are a Key Solution to Increased Access to Care

The 9 Counties that ACOG reported to have no OBGYNs: Modoc, Trinity, Glenn, Colusa, Sierra, Yuba, Mono, Alpine, and Mariposa.  Of these counties, 4 have midwives: Glen and Alpine both have Licensed Midwives, while Mariposa and Yuba have Nurse-Midwives

Midwives can be educated to provide maternity and sexual and reproductive health care much more quickly than an OBGYN , and at much lower cost. Because midwives can independently care for the vast majority of pregnant people, investment in midwifery pipeline and integration can have significant and rapid impact on workforce shortfalls.

Midwives tend to practice in communities with the most need.

  • Compared with physicians, a greater proportion of nurse-midwives practice in rural areas and Health Professional Shortage Areas (HPSAs).

  • Midwives are also more likely to care for women who are insured by Medicaid or from underserved populations. In a 2017 survey of California NPs and nurse-midwives, 72.6% of nurse-midwives responded “always,” “almost always,” or “to a considerable degree” when asked the extent to which they worked with underserved populations, and about one-third responded that between 76% and 99% of their patients were Medicaid beneficiaries.

Source: CHCF 2019 California’s Midwives: How Scope of Practice Laws Impact Care