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Can Patient Access to Midwife Care Eliminate Maternal Mortality Woes?

A Commonwealth Fund report indicated that by expanding patient access to midwife care, the US can address provider shortages and its maternal mortality and health equity crisis.

The US healthcare system, beleaguered by a maternal mortality and health equity crisis, needs to reconsider policies that can empower patient access to midwife care, according to a new policy brief from The Commonwealth Fund.

This will be especially important as the US also stares down a provider shortage issue and growing patient demand for midwifery care, especially in racial and ethnic minority populations.

What Are Midwives?

Midwives are licensed medical professionals who are most often thought of during the childbirth process, but The Commonwealth Fund researchers pointed out that midwives are also certified to deliver other types of primary and reproductive healthcare.

Midwifery prioritizes the patient-provider relationship, patient autonomy and self-determination, shared decision-making, and the healthcare environment.

There are three types of midwife credentials. Certified nurse-midwives (CNMs) and certified midwives (CMs) typically deliver care in the hospital setting, focusing on delivering babies and administering primary and reproductive healthcare for women. Certified professional midwives (CPMs) usually deliver more longitudinal prenatal and post-partum care in community and home-based settings.

Contrary to the “Little House on the Prairie” stereotype, most midwives actually deliver care in hospital settings. According to The Commonwealth Fund researchers, 87 percent of births led by a midwife happened in a hospital; 95 percent of the midwife workforce say they mostly work in a hospital setting.

By training, midwives do more than facilitate birth; they can perform physical exams, prescribe medications, admit and discharge patients, order and interpret labs, and order the use of medical devices. Midwives often do not actually carry out all of those tasks, the researchers added, because state and hospital policies often limit the scope of practice.

Benefits of Midwifery Care

Care administered by certified nurse-midwives/certified midwives (CNMs/CMs) is safe, with the report authors citing research from Medicaid demonstration projects in poorly resourced communities in California, Georgia, Kentucky, and New York consistently showing good outcomes.

Use of CNMs and CMs is linked with better patient satisfaction levels and lower healthcare costs. Moreover, CNMs and CMs have been linked to fewer cesarean sections, lower preterm birth rates, lower episiotomy rates, higher breastfeeding rates, and greater perceived patient autonomy, the researchers said.

Given these good outcomes, The Commonwealth Fund researchers argued that midwives could be useful in addressing healthcare’s workforce shortage and maternal mortality problems. The team cited a separate analysis showing that when midwives are better integrated into healthcare delivery systems, they could help provide around 80 percent of essential maternal care worldwide. They could also help prevent 41 percent of maternal deaths, 39 percent of neonatal deaths, and 26 percent of stillbirths.

Those care access improvements are particularly salient in the US, with half of US counties lacking even one OBGYN. Researchers have estimated that the US needs around 8,000 more OBGYNs to meet patient demands.

Barriers to Midwifery Care

The US does not have the regulatory setup to integrate midwives into maternity care, the researchers pointed out. That’s counter to the systems that other similarly developed nations—including Australia, Canada, the Netherlands, and the United Kingdom—have in place for facilitating patient access to midwife care.

“Lack of comprehensive insurance coverage for midwifery services, restrictive and archaic state and federal regulations that limit the practice of midwifery, and an absence of public subsidies for midwifery education are just a few of the reasons,” The Commonwealth Fund researchers explained.

“A multitude of social, political, historical, and economic factors are also at play, including the shift from community-based care to hospital-based care, the medicalization of childbirth that defined pregnancy as inherently risk-laden needing medical and technological interventions, and the history of sexism and racism in medicine.”

Those factors were disastrous for the midwifery profession, which has roots in Black culture in the South and immigrant culture in the Northeast. The researchers said only around 11 percent of births today are attended to by a midwife, and only 2 percent of births occur outside of hospital settings.

Potential Policy Changes that Support Midwifery Care

It’s time the US considers new mechanisms by which it can better integrate midwives into the healthcare system, particularly considering the patient demand, The Commonwealth Fund researchers argued.

Using 2016 figures from California, the researchers pointed out that patient desires for a midwife-led birth far outpace reality. For example, nearly half of Asian and Latina patients (48 and 51 percent, respectively) want a birth led by a midwife. However, only 8 percent of Asian people and 9 percent of Latina people actually had a midwife-led birth.

Midwifery is even more popular among White and Black people, with 59 and 66 percent wanting a midwife to attend to their births, respectively. Non-Hispanic White people were more likely to get a midwife if they wanted one, with 11 percent reporting a midwife-led birth. For Black people, that figure was 6 percent.

Healthcare industry stakeholders need to reconsider individual policies, both from a high-level and on the hospital level, to make room for more midwife care delivery. For one, allowing midwives to provide the full scope of services for which they are trained will ensure better patient access to care, including birthing services, pre- and post-natal care, primary care, and reproductive healthcare.

Hospitals may also consider tapping midwives to lead care delivery for low-risk pregnancies, leaving room for midwives to collaborate with physicians when a patient does present risk factors.

Allowing more practice authority for midwives is particularly important for the patient, The Commonwealth Fund researchers pointed out.

“Research suggests that, in the relationship between midwives and childbearing people, patients deeply value time together, trust, the ability to ask questions, and emotional support,” they noted. “To actualize these values, it is essential for midwives to be able to practice autonomously.”

Systems that enable midwifery care in all care settings, as well as providing midwifery as an insurance benefit, will ensure that all patients who want midwifery care can access it, the researchers explained.

Moreover, creating a diverse midwifery workforce will be important. Research shows that having a provider who is the same race can improve the patient experience and outcomes. But as it stands, the midwifery workforce is mostly White (95 percent), and only 30 percent can proficiently deliver services in Spanish.

Being that patient demand for a midwife is bigger in non-Hispanic Black populations, the healthcare industry should consider tools to ensure more Black people are able to get midwifery education.

But right now, there are major financial barriers to becoming a midwife that may impact individuals from traditionally marginalized backgrounds, including Black people and other racial/ethnic minorities. State and federal subsidies and financial assistance programs may help close this gap, the researchers posited.

“Until midwifery care is woven into the U.S. health ecosystem — with equal attention and investment across both hospital and community settings— the right to choose where, how, and from whom to receive maternity care will never be realized,” the researchers concluded. “This is a fundamental principle of reproductive justice that require more directed attention, investment, and strategic reform.”

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