Americans are more familiar with the vital work of nurse midwives than ever before, thanks in part to the PBS show “Call the Midwife.” Yet in the United States, midwifery is often seen as a fringe choice — something strange, or even perceived as “less than” when compared with OB-GYN care.
But in a country dealing with a maternal health crisis, that may all be about to change.
An increasing number of U.S. families are turning to midwives for their maternity care despite systemic, social, and cultural barriers.
“The midwifery model of care emphasizes normalcy and wellness. It empowers women and gives them greater ownership of their health, their pregnancy, and the outcomes of that pregnancy based on choices that they’re able to make,” explains Dr. Timothy J. Fisher, OB-GYN residency program director at Dartmouth Hitchcock Medical Center and assistant professor of obstetrics at the Geisel School of Medicine at Dartmouth University.
“Unfortunately, the medical model of prenatal care can take some of that ownership away, in a way that can ultimately be detrimental for some people,” he says.
WHAT’S THE MIDWIFERY MODEL?
Midwifery care involves a trusting relationship between the provider and pregnant person, who share decision-making. Midwives also see pregnancy and labor as normal life processes rather than a condition to be managed.
Millennials in particular may want something different than the medical model when they decide to have a baby.
Saraswathi Vedam, FACNM, a midwife for 35 years, midwifery researcher, and professor at the University of British Columbia, tells Healthline, “We have a generation of consumers now who are socialized that they should have a voice in making decisions about their own healthcare. In previous generations it was more normative to [give] control about healthcare decisions to the provider.”
“Another increase [in midwifery services] is in people who’ve had negative experiences in birth — or have been with family or a friend and witnessed something that scared them — and they don’t want the loss of bodily autonomy,” says Colleen Donovan-Batson, CNM, the director of the Midwives Alliance of North America Division of Health Policy and Advocacy.
Kendra Smith, an editor in San Francisco, was determined to have a nurse midwife as her care provider for her first pregnancy. Smith drove an hour and a half for every prenatal appointment so she could access her midwifery practice.
“I understood that midwives seemed to focus more on care for the whole woman during pregnancy, and felt that there was less likelihood of complications if I had a midwife,” she tells Healthline. “I thought it would be more likely that I’d be given the time to labor naturally, even in the hospital, if midwives and nurses were supporting me.”
That’s the level of assistance the midwifery model of care strives for. Midwives see pregnancy and labor as normal life processes rather than conditions fixed solely by medical professionals.
That doesn’t mean everyone who uses a midwife has to have a low-intervention birth or go without pain medications. The majority of midwives in the United States practice in hospital settings, accessible to a full range of medications and other options.
The 4 types of midwives, at a glance
Certified nurse midwives (CNM)
Certified nurse midwives or nurse midwives, have completed both nursing school and an additional graduate degree in midwifery. They’re qualified to work in all birth settings, including hospitals, homes, and birth centers. They can also write prescriptions in all 50 states. CNMs can also provide other primary and reproductive healthcare.
Certified midwives (CM)
Certified midwives have the same graduate-level training and education as certified nurse midwives, except they have a background in a health field other than nursing. They take the same exam as nurse midwives through the American College of Nurse Midwives. CMs are currently only licensed to practice in Delaware, Missouri, New Jersey, New York, Maine, and Rhode Island.
Certified professional midwives (CPM)
Certified professional midwives work exclusively in settings outside of hospitals, such as homes and birth centers. These midwives have completed coursework, an apprenticeship, and a national certifying exam. CPMs are licensed to practice in 33 states, though many of them work in states where they’re not recognized.
Traditional/unlicensed midwives
These midwives have chosen not to pursue licensure as a midwife in the United States, but who still serve birthing families in home settings. Their training and background varies. Often, traditional/unlicensed midwives serve specific communities, such as indigenous communities or religious populations like the Amish.
Benefits of midwives
In areas like the UK and the Netherlands, midwives are the standard providers of care for pregnancy and birth, attending over two-thirds of births. While shows like “Call the Midwife” and documentaries like “The Business of Being Born” have led some Americans to choose midwives as their care providers, they’re still vastly underutilized.
Currently, CNMs attend only about 8 percent of births in the United States. The majority of those are in hospital settings. Out-of-hospital births account for about 1.5 percent of all births. About 92 percent of these are attended by CPMs.
Midwifery care is safe — some say safer than physician care — for women and families at lower risk. People who use midwives report high levels of satisfaction with their care.
A 2018 research analysis found that, in hospital settings, people who have midwives are less likely to have cesarean deliveries, commonly known as C-sections, or episiotomies. Other research has found that people who birth with nurse midwives are more likely to breastfeed and less likely to experience a perineal laceration during birth.
Vedam and Fisher were authors on a recent study that examined all 50 states in terms of integration of midwives — including CNMs, CPMs, and CMs — into the healthcare system.
The study found that states with higher integration, such as Washington, had better outcomes for both mothers and babies. This equated to more natural births, less obstetric interventions, and fewer adverse neonatal outcomes than states with lower integration, such as Alabama and Mississippi.
5 things to know about midwives
Only 8 percent of births in the United States are attended by midwives. In the UK and other countries, they attend over two-thirds of births.
Research shows that people who use midwives often lead to better outcomes for mothers and babies.
Midwives treat women without children too. Over half of midwives say that reproductive care is one of their main responsibilities.
There are four kinds of midwives that range in schooling and certifications.
The majority of midwives practice in hospital settings.
Barriers to midwifery care
Midwifery care is often difficult to access, even for those who want it.
Midwives aren’t as readily available or accepted as part of the obstetric culture in some areas and regions. For example, there are currently only about 16 CNMs and 12 CPMs licensed to practice in the entire state of Alabama.
State-by-state regulation also limits midwifery practice for both CNMs and CPMs. This can make it more difficult for midwives to do their jobs and for consumers to understand midwives’ roles and choose them as providers.
For people who want to use midwives out of the hospital, barriers can be even greater. Some insurance, including Medicaid, won’t cover out-of-hospital birthing options, including birth centers. These out-of-pocket costs aren’t feasible for many families.
Midwives and women of color
Cultural competency, too, is an issue. A profound lack of midwives of color makes it even less likely that women of color will access midwifery care.
Currently, black women in the United States are three to four times more likely to die in the perinatal period than white women and, according to the March of Dimes, are 49 percent more likely to give birth prematurely.
This disparity may be because providers may underestimate the pain of black patients or dismiss their symptoms. Serena Williams is one example. She had to demand her doctors check for blood clots after the cesarean delivery of her daughter in 2017.
Midwifery care could make a difference in birth experiences for black women. Yet it can be next to impossible for black women to find midwifery providers who look like them.
Racha Tahani Lawler, a black CPM who’s been practicing for 16 years, estimates that there are less than 100 black CPMs in the entire country. As of 2009, 95.2 percent of CNMs identified as Caucasian.
Many of Lawler’s clients aren’t aware of midwifery or home birth options, she says, until they have a bad experience. “The catalyst for most black people is ‘I don’t like the way they’re treating me,’ or ‘I feel like I am being harmed in my appointments,’” she says.
Veronica Gipson, a mother in Los Angeles, chose home birth with Lawler after three birth experiences at hospitals that she felt were disappointing, disrespectful, and racialized. Although she came to Lawler with just about a month left in her fourth pregnancy, Lawler worked with her to establish care and a payment plan.
Gipson says it was more than worth it, although she was at first intimidated by the cost of home birth midwifery: “It’s so helpful to have someone who looks like you and understands you. It’s a priceless feeling, a bond and relationship. I’m not just room 31 in the hospital — I’m Veronica when I’m with Racha.” Gipson has since had Lawler attend the birth of her fifth child.
The future of midwifery in the United States
Maternal health experts say midwifery could be a viable option to help solve a number of ills in the American maternal healthcare system, including:
lowering the maternal mortality rate
making care more affordable
helping to solve the crisis of the dwindling numbers of maternity care providers
Still, there’s a long way to go before midwives are fully and successfully integrated into the U.S. healthcare system.
Vedam believes it’ll take systems-level collaboration before midwifery is both accepted and integrated: “Healthcare administrators, health policy makers, researchers, providers, the public — everyone will need to work together.”
But consumers with resources or access to healthcare coverage can still vote by seeking midwifery care and making it known that they want midwives in their communities, adds Vedam.
Donovan-Batson of the Midwives Alliance of North America feels that when people better understand the true benefits of midwifery care, they’ll be requesting it.
“Research shows us that midwife care is the safest care for a low-risk woman. We’re the experts in normal pregnancy and birth. So, if you want to have that normal experience, seek out a midwife who will work with you to get you the care that you desire.”
And if that day of full acceptance ever comes, there’s a good chance American mothers and babies may be in better care.