Abstract
This contribution reprints the Executive Summary from a technical report issued by the National Partnership for Women & Families within its larger Improving Our Maternity Care Now project. This project identifies the priority of continuing the long, challenging work of maternity care system transformation, while also increasing access to high-performing care models that can help meet current urgent, dire needs for equitable high-quality care now. The Midwifery report is the first in a series of four reports on these care models, which share distinctive features. They reliably provide highly appropriate services that minimize both underuse of beneficial practices and overuse of unneeded, often harmful practices. They prioritize relationship-based, whole person care that builds trust, confidence and resilience and helps meet the varied needs of birthing families. They incorporate skills and knowledge to support the innate physiologic processes of birthing people and their fetuses/newborns. They achieve remarkable results for consequential outcomes relative to standard maternity care. And childbearing people greatly desire access to these forms of care relative to current access and use. Community-based versions offering trustworthy, respectful, culturally-congruent care are especially powerful. The midwifery report includes recommendations for federal policymakers, state policymakers, and private sector decision makers to increase access to midwifery care. It was carried out in partnership with the American College of Nurse-Midwives, the National Association of Certified Professional Midwives, and the National Black Midwives Alliance. Access the full project through https://www.nationalpartnership.org/improvingmaternitycare/. The project is supported by the Yellow Chair Foundation and is reprinted with permission. Reproduced with permission of the National Partnership for Women & Families.
Keywords: midwifery, birth justice, maternal health, maternal health policy
EXECUTIVE SUMMARY
Our nation’s maternity care system fails to provide many childbearing people1 and newborns with equitable, accessible, respectful, safe, effective, and affordable care. More people die per capita from pregnancy and childbirth in this country than in any other high-income country in the world. Our maternity care system spectacularly fails communities struggling with the burden of structural inequities due to racism and other forms of disadvantage, including Black, Indigenous, and other communities of color; rural communities; and people with low incomes.
Both the maternal mortality rate and the much higher severe maternal morbidity rate (often reflecting a “near miss” of dying) have been increasing, and both reveal inequities by race and ethnicity. Relative to White non-Hispanic women, Black women are more than three times as likely—and Indigenous women are more than twice as likely—to experience pregnancy-related deaths. Moreover, Black, Indigenous, Hispanic, and Asian and Pacific Islander women disproportionately experience births with severe maternal morbidity relative to White non-Hispanic women.
This dire maternal health crisis, which has been compounded by the COVID-19 pandemic, demands that we mitigate needless harm now.
Fortunately, research shows that there are specific care models that can make a concrete difference in improving maternity care quality and producing better outcomes, especially for birthing people of color. One of these models is midwifery care. This report outlines the evidence that supports midwifery’s unique value across different communities, the safety and effectiveness of midwifery care in improving maternal and infant outcomes, the interest of birthing people in midwifery care, and the current availability of, and access to, midwifery services in the United States. We also provide recommendations for key decisionmakers in public and private sectors to help support and increase access to midwifery care.
Research shows that midwifery care provides equal or better care and outcomes compared to physician care on many key indicators, including higher rates of spontaneous vaginal birth, higher rates of breastfeeding, higher birthing person satisfaction with care, and lower overall costs. Community-based and -led midwifery services are especially powerful. Yet in the United States, midwives attend only about 10 percent of births; in nearly all other nations, midwives provide the majority of first-line maternity care to childbearing people and newborns, with far better outcomes.
Expanding the availability of midwifery care is a cost-effective solution to providing higher quality care and better birth outcomes. Barriers to this modality of care must be eliminated. These include: Lack of support and funding for midwifery education, inconsistent Medicaid reimbursement for midwifery services, lack of state-level recognition of all nationally recognized midwifery credentials, and restrictive state practice laws that prohibit midwives from practicing to the full scope of their competencies and education.
Enabling more birthing people to receive care from midwives while diversifying the profession of midwifery should be a top priority for decisionmakers at the local, state, and federal levels. To achieve this, we recommend the following:
FEDERAL POLICYMAKERS SHOULD:
Enact the bipartisan Midwives for Maximizing Optimal Maternity Services (Midwives for MOMS) Act (H.R. 3352 and S. 1697 in the 117th Congress) to increase the supply of midwives with nationally recognized credentials (certified nurse-midwives, certified midwives, certified professional midwives), racially and ethnically diversify the midwifery workforce, and increase access to care in underserved areas.
Mandate equitable payment for midwifery services by all federal health programs and make certified midwives and certified professional midwives eligible for federal loan repayment from the National Health Service Corps.
Prohibit hospitals from denying admitting and clinical privileges to midwives as a class.
Require the collection and public reporting of data related to health inequities, such as racial, ethnic, socioeconomic, sexual orientation, gender identity, language, and disability disparities in critical indicators of maternal and infant health—including, but not limited to, maternal mortality, severe maternal morbidity, preterm birth, low birth weight, cesarean birth, and breastfeeding.
STATE AND TERRITORIAL POLICYMAKERS SHOULD:
Ensure that their states license and regulate all nationally certified midwifery credentials.
Amend restrictive midwifery and nurse practice acts to enable full-scope midwifery practice, in line with their full competencies and education as independent providers who collaborate with others according to the health needs of their clients.
Mandate reimbursement of midwives with nationally recognized credentials at 100 percent of physician payment levels for the same service in states without payment parity.
In states where Medicaid agencies do not currently pay for the services of licensed midwives holding nationally recognized midwifery credentials, mandate payment at 100 percent of physician payment levels for the same services.
PRIVATE SECTOR DECISIONMAKERS, INCLUDING PURCHASERS AND HEALTH PLANS, SHOULD:
Incorporate clear expectations into service contracts about access to, and sustainable payment for, midwifery services offered by providers with nationally recognized credentials.
Educate employees and beneficiaries about the benefits of maternity care provided by midwives with nationally recognized credentials.
Mandate that plan directories maintain up-to-date listings for available midwives.
In all relevant deliberations, consistently engage early and proactively with community-based midwives bringing a birth justice framework. This involves their meaningful decision-making roles in shaping policy priorities and strategies, and diverse representation that reflects the demographic makeup of adversely affected communities.
ACKNOWLEDGMENTS
We are grateful to the Yellow Chair Foundation for its generous support of this work. Contributions of the following partners strengthened this report in a myriad of ways: Karen Jefferson and Amy Kohl of the American College of Nurse-Midwives, Mary Lawlor of the National Association of Certified Professional Midwives, and Jamarah Amani and Kim Banton of National Black Midwives Alliance.
Biographies
CAROL SAKALA is the Senior Director for Maternal Health, National Partnership for Women & Families.
SINSI HERNÁNDEZ-CANCIO is the Vice President for Health Justice, National Partnership for Women & Families.
ERIN MACKAY is Managing Director for Health Justice, National Partnership for Women & Families.
RACHEL WEI is an OB Practice Consultant, Anthem, Inc.
NOTE
We recognize and respect that pregnant, birthing, postpartum, and parenting people have a range of gender identities, and do not always identify as “women” or “mothers.” In recognition of the diversity of identities, this report gives preference to gender-neutral terms such as “people,” “pregnant people,” and “birthing persons.” In references to studies, we use the typically gendered language of the authors.
DISCLOSURE
The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
FUNDING
The Yellow Chair Foundation supported this work.