How Expanding the Role of Midwives in U.S. Health Care Could Help Address the Maternal Health Crisis

Introduction

Midwives are licensed health care providers who offer a wide range of essential reproductive and sexual health care services, from birth and newborn care to Pap tests and contraceptive care. Research consistently demonstrates that when midwives play a central role in the provision of maternal care, patients are more satisfied, clinical outcomes for parents and infants improve, and costs decrease.¹ Use of midwives is also associated with fewer cesarean sections, lower preterm birth rates, lower episiotomy rates, higher breastfeeding rates, and a greater sense of respect and autonomy for the patient.²

It’s not difficult to imagine that midwifery could play a role in addressing tenacious perinatal health disparities in the United States. In 2021, the U.S. had 32.9 maternal deaths per 100,000 births, more than 10 times that of countries like Australia, Japan, Israel, and Spain, where rates remain between two and three per 100,000.³ Maternal mortality rates are rising across all races and ethnicities in the U.S. — Black women are dying at nearly triple the rate of white women, and Native American women at double the rate. Additionally, data from maternal mortality review committees suggest that four of five pregnancy-related deaths are preventable.⁴

A recent analysis found that a midwife workforce, integrated into health care delivery systems, could provide 80 percent of essential maternal care around the world and potentially avert 41 percent of maternal deaths, 39 percent of neonatal deaths, and 26 percent of stillbirths.⁵ Midwives also could help address the workforce shortages that loom large in the U.S. maternity care landscape: nearly half of U.S. counties lack a single obstetrician-gynecologist, and it’s estimated that the nation needs 8,000 more to meet demand — a number that, by one estimate, may rise to 22,000 by 2050.⁶

However, unlike other high-income countries such as Australia, Canada, the Netherlands, and the United Kingdom, the United States does not systematically incorporate midwives into essential maternity care services. 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. 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. These factors systemically eroded the midwifery profession and nearly decimated the community-centered approach used by Black midwives in the South and immigrant midwives in the Northeast.⁷ Today, as a result, only 11 percent of births in the U.S. are attended by a midwife and only 2 percent of births occur outside of hospital settings.⁸

Given the many benefits of midwives, and the profound maternal care inequities affecting Black and Indigenous families in the U.S., it’s important to understand how they could be better integrated into the U.S. health care system. This includes the intentional integration of midwifery across the complex health care ecosystem in order to ensure midwifery care is accessible, affordable, and equitable to all childbearing people.

The Midwifery Model of Care

The midwifery model takes a holistic, relationship-centered approach to the pregnancy and birthing continuum.⁹ Its philosophy of care is rooted in four principles:

1. Care that is built on a trusting and respectful relationship between the midwife and the childbearing person.
2. Care that prioritizes and encourages the parent’s autonomy, self-determination, and satisfaction.
3. Informed decision-making in partnership with the childbearing person.
4. An environment of care that creates a sense of safety and assurance for client and midwife.¹⁰

In addition to caring for people during pregnancy and childbirth, midwives in the U.S. can: conduct physical examinations; prescribe medications, including controlled substances and contraceptives; admit, manage, and discharge patients; order and interpret laboratory and diagnostic tests; and order the use of medical devices. However, state and hospital policies often limit the capacity of midwives to practice to their full scope.

Three-quarters (76%) of certified nurse-midwives/certified midwives (CNMs/CMs) in the U.S. undertake reproductive care in their full-time positions, and 49 percent have primary care responsibilities.¹¹ This could include the independent provision of sexual and reproductive health, which also includes primary gynecological care, family planning services, preconception care, care of newborns during the first 28 days of life, and treatment of sexually transmitted infections.

Midwives have a long history of providing high-quality, high-touch care to meet both the physiological and psychosocial needs of historically disenfranchised communities.¹² Additionally, demonstration projects of nurse-midwifery services located in underserved, poorly resourced communities in California, Georgia, Kentucky, and New York consistently showed safe neonatal and maternal outcomes.

Midwifery in the U.S.

While midwifery in the United States is often associated with births in the community, including in homes and birth centers, 87 percent of midwife-attended births in 2020 were in hospital settings in collaboration with nurses and physicians.¹³ In fact, most of the U.S. midwifery workforce (95%) reports working exclusively in hospital settings.

There are three different midwifery credentials in the U.S.: certified nurse-midwives (CNMs), certified midwives (CMs) and certified professional midwives (CPMs). Although they have different educational and regulatory pathways, they have similar competencies and a shared commitment to a person-centered, midwifery care model. Most CNMs/CMs attend births in hospitals, with a smaller number providing care at homes and at birth centers. CNMs/CMs also provide primary care and primary women’s health care, including contraception and abortion. Scope of practice for CPMs is in most cases focused on care across the course of a pregnancy and newborn care in community settings like homes and birth centers.¹⁴

The COVID-19 pandemic saw a notable increase in people choosing to give birth outside of hospital settings. Community births increased by 19.5 percent in 2020 — planned homebirths by 23.3 percent and deliveries in birth centers by 13.2 percent. Increases occurred in every state and for all racial and ethnic groups, most dramatically for non-Hispanic Black birthing parents (29.7%). This shift was linked to concerns about contracting the coronavirus in hospital settings, protocols like limitations or bans on support people in the hospital, and the separation of infants from mothers suspected to be COVID-positive. These factors likely spurred interest in, and greater acceptance of, giving birth in community settings with midwives.¹⁵

While demand for midwifery care in both hospital and community settings grows, much of it remains unmet. A California-wide survey recently demonstrated significant mismatch between the desire to be cared for by a midwife and the actual use of midwifery in childbirth, with Black childbearing people experiencing the biggest gap between demand and access (Exhibit 1).¹⁶

The needs and desires of childbearing people and the different contexts and settings of midwifery in the U.S. are all critical starting points for maternity care transformation.¹⁷ Choosing a maternity care provider and setting in the U.S. requires navigating a complex network of barriers like insurance coverage, federal policies, and state-level regulations on both midwifery practice and community birth settings. While most U.S. births take place in hospital settings, not all hospitals provide perinatal care, or access to midwifery care providers. Insurers also limit access to midwifery care and coverage for community birth options, so people’s preferences may often be inaccessible.¹⁸

Compared with hospital births, planned community births are also far more likely to be paid for out of pocket because of gaps in public and private insurance coverage. In more than half of U.S. states, over 70 percent of planned home births and 32 percent of birth center care were self-paid, while only 3.4 percent of hospital births were self-paid.

Integrating Midwifery into U.S. Maternal Care

The full integration of midwifery into U.S. health care delivery will require reforms at the professional, institutional, delivery system, and policy levels. Some examples include:

• Supporting practices and policies for midwives to provide the full scope of services across the care continuum without being limited to specific facets, such as only providing prenatal care or only providing care during labor and birth.
• Restructuring hospital bylaws to allow midwives to be the principal providers for low-risk pregnancies and to collaborate with physicians when risk factors are present.
• Ensuring midwifery care is accessible to everyone in all care settings, from freestanding birth centers to public community clinics and tertiary care facilities, and is equitably reimbursed by insurers.
• Guaranteeing insurance coverage for midwifery care and eliminating federal and state regulations that undermine equitable access to midwifery care across birth settings.¹⁹

Currently, the degree to which midwifery care is integrated into essential maternity care varies dramatically across states. The Midwifery Integration Scoring System attempted to assess and compare the state-level practice environment for midwifery, using factors such as professional autonomy, scope of practice, prescriptive authority, restrictions on practice, and access across birth settings. Application of this tool showed that states with highly integrated midwifery care — such as Washington, New Mexico, and Oregon — reported the best outcomes for mothers and infants, which included significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death (Exhibit 2). On the other hand, states with restrictive midwife laws and practices — including Alabama, Mississippi, and Ohio — were found to have worse outcomes.²⁰

Regulatory Requirements

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.²¹ To actualize these values, it is essential for midwives to be able to practice autonomously. Professional autonomy means midwives practice as independent providers that do not require physician “supervision.” To date, many state laws persistently require physician supervision and/or contractual practice agreements with physicians, ranging from supervision for all practice to supervision for prescriptive authority. States with laws that ensure autonomous midwifery practice have a more robust midwifery workforce that can attend more births and achieve better outcomes.²²

Current hospital bylaws and other regulatory and legislative restrictions limit the growth of a robust midwifery workforce. Perinatal equity requires removing archaic laws and outdated policies designed to restrict midwifery practice and consolidate the power of physicians and hospital-based care.

Education

While medical residencies are funded through graduate medical education programs, there is no comparable federal program to subsidize midwifery education and training, placing the financial burden of becoming a midwife directly on the student.²³ Health care systems are therefore incentivized to educate obstetrical residents over midwifery students. The lack of financial support poses a significant barrier to entry for members of marginalized groups, perhaps contributing to the lack of racial diversity in the midwife workforce. One survey found that 90 percent of U.S. midwives identify as white/non-Hispanic, with Black or African American (6%), Native American (less than 1%), and Asian American (less than 2%) midwives constituting a small minority. Most also identified English as their primary language (96%), with 30 percent providing services in Spanish and 8 percent in other languages. Growing a culturally and racially representative midwifery workforce will require significant and sustainable federal and state-level investments in free/low-cost education for midwifery students.

Insurance Coverage

Inequitable Medicaid reimbursement rates and related state laws and regulations limit the adoption of midwives and community-based care models. While Medicaid reimbursement for CNM care is mandatory, reimbursement equity between midwives and physicians varies from state to state.²⁴ In some states, physicians attending a vaginal birth are reimbursed at a higher rate than midwives providing the same services.

Private insurance coverage also varies by insurer and state, leading to inequitable access to midwifery care across the United States — a particularly acute problem for those seeking care in community settings. The Center for Medicare and Medicaid Innovation found that Black and Hispanic women, who are more likely to be uninsured or enrolled in Medicaid, have limited to no access to midwifery-led care.²⁵ One potential solution is to mandate that public and private insurance plans have robust networks of midwifery care providers that can deliver comprehensive and equitable coverage of pregnancy- and postpartum-related health care across birth settings.

Midwives, particularly those practicing in home settings, also struggle to access and afford malpractice insurance. Policies that require insurers to provide midwives with malpractice coverage also will be critical for integrating U.S. midwives with the broader maternity care system.

Conclusion

Building midwifery capacity and integrating midwives into the U.S. health care system are critical to addressing this country’s maternal and reproductive health crisis. Both require upstream policy changes related to licensing, insurance reimbursement, federal educational subsidies, and hospital credentialing, complemented by downstream strategies for educating health care and hospital leadership — particularly obstetricians — about the value of midwifery in improving care outcomes. Combined, these changes can help improve access to comprehensive, safe, and high-quality maternity care for pregnant and birthing people.

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. This is a fundamental principle of reproductive justice that require more directed attention, investment, and strategic reform.