Today’s podcast episode is focused on a very important topic— the Evidence on Midwives.
We’ve been asked by years to publish an article or podcast on the evidence on midwifery care, and we felt there was no better day to release a podcast episode on this topic than May 5th, International Day of the Midwife!
In this episode, I discuss the different types of midwives, the history of midwifery care (and how it was nearly eliminated in the U.S.) and the research on the better health outcomes that are seen when families are randomly assigned to receive midwifery-led care. We also talk about the effects of racism and mistreatment in obstetric care, and how midwives — especially midwives of color— are a critical solution to the maternal mortality crisis in the U.S.
With the theme of the 2021 International Day of the Midwife being, “Follow the data and invest in midwives,” we are honored in this podcast episode to talk about why we need more midwives of color, and to acknowledge the Black grand midwives who have recently transitioned from elders to ancestors.
Content warning: In this episode we talk about miscarriage, fetal loss, and racism.
Learn more about Nicole Deggins and Sista Midwife here (https://www.sistamidwife.com/). Follow Nicole Deggins on Facebook here (https://www.facebook.com/SistaMidwife), and on Instagram here (https://www.instagram.com/sistamidwife). Listen to Nicole Deggins’ EBB podcast episode here (https://evidencebasedbirth.com/nicole-deggins-of-sista-midwife-productions-on-navigating-systemic-racism-in-birth-work/).
Read more about Dr. Mimi Niles and Dr. Michelle Drew’s article, “Constructing the Modern American Midwife: White Supremacy and White Feminism Collide” here (https://nursingclio.org/author/paulomi-niles/).
Learn more about Frontier Nursing University here (https://frontier.edu/about-frontier/).
Learn more about Jennie Joseph and Commonsense Childbirth School of Midwifery here (https://commonsensechildbirth.org/). Learn more about The JJ Way here (https://savinglives.biz/the-jj-way/). Follow Jennie Joseph on Facebook here (https://www.facebook.com/MidwifeJennie/), Instagram here (https://www.instagram.com/iamjenniejoseph), and Twitter here (https://twitter.com/JennieJoseph). Listen to Jennie Joseph’s EBB podcast episode here (https://evidencebasedbirth.com/solutions-for-the-crisis-in-american-maternity-care-with-jennie-joseph/).
Learn more about Shafia Monroe and SMC Full Circle Doula Birth Companion Training here (https://shafiamonroe.com/). Follow Shafia on Instagram and Black Midwife Cooking here (https://www.instagram.com/shafiamonroe/). Follow Shafia on Twitter here (https://twitter.com/Shafia_SMC). Follow Shafia on Facebook here (https://www.facebook.com/shafiamonroeconsulting/). Listen to Shafia Monroe’s EBB podcast episode here (https://evidencebasedbirth.com/shafia-monroe-on-traditional-black-midwifery-spirituality-and-community-advocacy/).
Learn more about Charlotte Shilo-Goudeau here (https://www.midwifecharlotte.com/).
Learn more about Uzazi Village in Kansas City here (https://uzazivillage.org/).
Follow the Jamaa Birth Village on Facebook here (https://www.facebook.com/jamaabirthvillage/), Instagram here (https://www.instagram.com/jamaabirthvillage/), Twitter here (https://twitter.com/jamaabirth?lang=en). Learn more about the Jamaa Birth village here (https://jamaabirthvillage.org/). Follow Brittany Tru Kellman, CPM on Facebook (https://www.facebook.com/TruKellman/). Listen to Brittany “Tru” Kellman’s EBB podcast episode here (https://evidencebasedbirth.com/community-black-midwifery-and-advocacy-with-brittany-tru-kellman-of-jamaa-birth-village/).
Learn more about Roots Community Birth Center here (https://www.rootsbirthcenter.com/).
Learn more about the San Antonio Nurse Midwife Birth and Wellness Center here (https://sanantonionursemidwife.com/).
Learn more about Birth Detroit here (https://www.birthdetroit.com/).
Learn more about Choices in Memphis here (https://memphischoices.org/).
Learn more about Abide Women’s Health Services here (https://www.abidewomen.org/).
Learn more about Nicolle Gonzales and Changing Woman Initiative here (http://www.changingwomaninitiative.com/).
Learn more about Birth Center Equity here (https://birthcenterequity.org/).
Learn more about Patricia Loftman here (https://perinataltaskforce.com/patricia-o-loftman/).
Learn more about Helena Grant here (https://hgrantstyle.com/).
Learn more about the American College of Nurse-Midwives here (https://www.midwife.org/) and ACNM Board of Directors here (https://www.midwife.org/ACNM-Board-of-Directors-1955-Present).
Learn more about the Midwives of Color Committee here (https://quickening.midwife.org/roundtable/diversity-inclusion/acnm-and-the-midwives-of-color-committee-mocc-celebrate-black-history-month/).
Learn more about Birth Place Lab Maps here (https://birthplacelab.org/maps).
Learn more about The Giving Voice to Mothers study here (https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0729-2).
Learn more about Melanated Midwives here (https://melanatedmidwives.org).
Learn more about the National Black Midwives Alliance here (https://blackmidwivesalliance.org/).
Learn more about the Black Mamas Matter Association here (https://blackmamasmatter.org/).
Learn more about the National Birth Equity Collaborative here (https://birthequity.org/).
Learn more about the Southern Birth Justice Network here (https://southernbirthjustice.org/).
Learn more about Sister Song here (https://www.sistersong.net/).
Sandall et al (2016). “Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting.” Cochrane Database of Systematic Reviews; 4:CD004667 [Link: https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early]
Vedam et al. (2018). “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.” PLoS ONE 13(2). [Link: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523].
Cheyney et al. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery and Women’s Health, 59(1): 17-27. [Link: https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12172]
Rebecca Dekker: Hi everyone. On today’s podcast, we’re going to talk about the evidence on midwifery care. Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Hi everyone. Today is International Day of the Midwife, May 5, and we thought there was no better way to celebrate at EBB than to talk about the research evidence on how midwives save lives and impact outcomes around the globe. Just a quick content warning before we get started. In today’s episode, we will be discussing statistics of newborn and maternal mortality, as well as the effects of racism and mistreatment in obstetric care.
The International Day of the Midwife has been celebrated every year since 1992. Led by the International Confederation of Midwives or ICM, this is a day of global recognition and celebration of midwives around the world. It’s recognized by more than 50 nations, and it’s coordinated by the ICM. You can visit their website at internationalmidwives.org.
The theme of the 2021 International Day of the Midwife is actually, “Follow the data and invest in midwives.” So that’s what I want to talk about today. I want to talk about the data, supporting midwifery care around the world. In many countries around the world, midwives actually make up the vast majority of the obstetric care workforce. For example, in the United Kingdom, there are more than 31,000 midwives compared to 6,000 obstetricians.
In Germany, there are around 24,000 midwives compared to around 4,000 Obstetricians and in Japan there are more than 25,000 midwives compared to less than 8,000 OBs. This is in contrast the situation in North America. In the United States, there are about 12,000, certified nurse midwives, and 102 certified midwives and about 2,400 certified professional midwives. This is in comparison to 43,000 obstetricians in the United States. In Canada, there are roughly 1,900 midwives compared to more than 2,000 obstetricians.
In the United States, there are typically around 4 million births each year, and the majority of these births are attended by physicians, with only about 9% attended by certified nurse midwives, or certified midwives, and less than 1% attended by certified professional midwives or traditional midwives. Now, if you only look at vaginal births, midwives do attend a higher proportion of vaginal births in United States, but still only about 14%.
In 2012, Dr. Eugene de Klerk analyzed birth certificate data in the US and found that there had been a recent rise in the percentage of births attended by nurse midwives. In 1990, only 3.6% of all births were attended by nurse midwives, and by 2017, that had risen to 9.1% of all births. Before I go any further into the data, let me clarify some of the different types of midwives in the United States. A direct entry midwife is someone who goes straight into studying midwifery without going through nursing school beforehand.
Direct entry midwifery is quite common around the world and it’s typically the norm in other countries. In the United States, the direct entry Certified Professional Midwife or CPM credential was launched in 1994. About half of all CPMs graduate from an accredited midwifery education program, and the other half learn the profession through a formal apprenticeship. Regardless of which educational path they take, all CPMs learn the same content and take the same national certification examination.
However, CPMs make up the minority of midwives in the United States. The most common type of midwife in the US is a certified nurse midwife, CNM, a midwife who goes through nursing school first and then completes an academic graduate program in nurse midwifery. CNMs graduate with master’s degrees and are qualified to provide labor and delivery care and also well woman care throughout the course of someone’s lifespan. In the United States, the CNMs work primarily in hospital settings, while CPMs work only in community settings in freestanding birth centers and at-home births.
There are also about 100 certified midwives in the United States. Certified midwives are people with a background in science or health related field other than nursing, who graduate from a master’s level midwifery education program. They have a similar training and scope of practice to CNMs, but they’re not required to have a nursing background. Certified midwives practice in eight states. Interestingly, the US is the only country in the world with such a split system of different kinds of professional midwifery.
Certified nurse midwives are licensed to practice in all 50 states, although they may have some restrictions in different states and licensure for certified professional midwives varies by state as well. There is a lack of consistency among the states with how midwives are regulated. For example, in some states certified professional midwives cannot practice at all. In other states, certified professional midwives are licensed to attend home births, but certified nurse midwives are only permitted to practice in hospitals and it’s illegal for them to attend home births. Whereas in other states, they have full practice privileges both in homes, hospitals, and freestanding birth centers.
There are also traditional midwives. With traditional midwives, these are midwives who are attending home births and they’re not certified or licensed. For religious, personal or philosophical reasons, they choose to continue the midwifery tradition as it has been throughout history, a personal social contract between the midwife and the client, without the involvement of certifying, accrediting or governmental agencies.
Traditional midwives often belong to communities with strong religious or cultural or ethnic ties, and they believe that they are accountable to the communities they serve. Education involves self study and apprenticeship with more experienced midwives passing their knowledge to less experienced midwives. We can’t really talk about the data and the research on midwifery care without discussing some of the history and how midwifery began and how in the United States, it was nearly eliminated.
Throughout most of human history, childbirth was a female-led, community-oriented activity. A midwife was often a local woman who had experienced giving birth themselves and who felt called to help other women, with or without special training or payment for their services. Over time, midwifery developed as a formal profession of women helping other women through this major life event, passing on wisdom, training and knowledge about birth to each other, through either formal education programs, apprenticeship, or usually both.
Most people don’t realize that midwives have been around a lot longer than physicians. When the medical specialty of obstetrics was developed a few 100 years ago, exclusively by men, pregnancy was viewed as a disease and in many ways, birth was something to be feared and managed, but before the onset of physicians, before the last few 100 years, midwives were the exclusive birth attendants around the world.
Each culture had their own midwives. Hebrew midwives played an important role in the Bible. Legendary Black grand midwives brought their knowledge from West Africa to the US, attending the birth of most Black and white women in the Old South. European midwives passed their considerable wisdom down through the generations and across the ocean. You have the many midwives who immigrated to the US from the 1600s to the 1900s.
Indigenous midwives of the Americas attended births of their community members before the medicalization of birth, and they continue to work today to preserve and advance traditional midwifery. However, as I mentioned earlier, less than 10% of all births have a midwife attendant in the United States. Also, the Black grand midwives are almost gone and the vast majority of midwives practicing in the United States are white, with very few women of color working in the midwifery profession.
The American Midwifery Certification Board released a demographic report in 2019, stating that the majority of certified nurse midwives and certified midwives identified as white, 87%, with midwives, who identified as Black or African American making up 6.3% of all midwives. Other visible minorities comprise less than 10% of midwives.
About 120 years ago in the year 1900 in the US, more than 95% of births were still happening at home. About half of these were attended by midwives and half by physicians, many of whom were general practitioners or family doctors. The midwife attended birth rate was even higher among ethnic minorities and people living in rural areas. For example, in my state of Kentucky in the year 1922, grand midwives or granny midwives attended 85% of births to people in rural Kentucky.
Unfortunately, around this time, obstetricians and the American Medical Association began realizing that childbirth was a huge market and they were right in predicting this. Today, hospitalizations for pregnancy, childbirth, and newborn care make up one out of four hospital stays in the United States. But the obstetricians in the early 1900s had a problem. They called it the “midwife problem,” and they began a concerted effort to eliminate midwives in the United States.
Sadly, they found it to be a pretty easy task. More than 100 years ago, all the midwives in the United States were female, and many of them were Black, Brown skinned, or immigrants. They did not share the same language. They did not have the same culture and they often didn’t even know of the other’s existence. They were not able to form a national association or any kind of coalition that could have stopped the abolishment of midwifery.
Despite their considerable skills and the fact that many of them were professionally educated, most midwives were stereotyped as, “uneducated.” Male physicians were horrified that women were working as midwives because at the time, it was still thought that women were mentally unfit to make decisions about themselves or about others.
At this time, in the early 1900s midwives were still providing safer care and had lower maternal mortality rates than physicians, but obstetricians and allied medical and public health professionals, including nurses, devised a three-pronged approach to take over the market. They launched a national propaganda campaign to convince the public that midwives were dirty, foreign and ignorant.
Second, they began systematically changing state and local laws to either outlaw midwifery, or tightly restrict midwifery practice. Many of these laws required midwives to be, “supervised by physicians,” and physicians who were supportive of midwifery care often found themselves being chased out of town, or stigmatized, because they supported the midwives. Third, obstetricians also sought to lower the public’s opinion of family doctors or general practitioners.
By eliminating midwives, and making it harder for general practitioners to attend births, obstetricians solidified a monopoly on the delivery market, and they were particularly intent on making sure that they had enough delivery cases to train the obstetrician, residents and medical students in their specialty. Not only did this campaign nearly eliminate midwives in the United States, but also ensured that future generations of midwives who existed would primarily be white.
At first, the southern Black grand midwives were given licenses to practice in their states, but within a few years their licenses were revoked, forcing midwives to retire or stop practicing in their communities in order to avoid prosecution. Segregation was the law of the land in the south, and Black and Indigenous midwives were not permitted to attend educational programs in the south where white nurse midwives were being taught, such as Frontier Nursing Service.
You can read an excellent article by Dr. Mimi Niles and Dr. Michelle Drew, both certified nurse midwives, about how white supremacy led to a midwifery workforce in the United States that is largely white. The article is called “Constructing the Modern American Midwife: White Supremacy and White Feminism Collide”. In this article, they outline the history of midwifery in the United States and talk about Mary Breckinridge, who many considered to be the mother of nurse midwifery in the United States.
How Mary Breckinridge started Frontier Nursing Service in Kentucky, and how this educational program did not admit a single Black nurse until Mary Breckinridge died in 1965. The Frontier Nursing Services also talked about as the nurse midwives on horseback who would ride to attend births in rural Kentucky, near where I live today. But Black women in the service area did not receive care from the all white workforce of nurse midwives.
Dr. Niles and Dr. Drew write, “FNS nurse midwives denounced the work of the local granny midwives as a way to uplift their own professional status, while systematically replacing them as the region’s birth attendants. The school is on and is one of the largest nurse midwifery schools in the country.” “Today, they write, “There are 39 graduate programs that train certified midwives and nurse midwives, only two with Black program directors. However, over the past several decades, a small but mighty and growing number of Black and Indigenous midwives are reclaiming their heritage and legacy and building on the work of the Black gran midwives, and the Indigenous midwives, who are their ancestors.”
In 2020, Jennie Joseph became the first Black owner of an accredited midwifery school in the United States, Commonsense School of Midwifery. Shafia Monroe is a renowned midwife who began practicing as a traditional midwife in Boston in the 1970s, and today is training thousands of Black doulas and future midwives. She also leads training in continuing education classes on the history of traditional midwifery in the Black community.
I’d like to acknowledge the Black Certified Professional Midwives in the state of Louisiana, some of whom are pictured in the featured photo for the blog article that goes along with this podcast. Ms. Lynette Elizalde-Robinson is the first documented Black CPM and Licensed Midwife in Louisiana. She served as preceptor for Ms. Shatamia Alexander Webb and Ms. Charlotte Shilo-Goudeau. Together, they serve families in rural Louisiana who desire birth center birth, or home birth, along with student midwife Ms. Divine Bailey-Nicholas. here are a number of Black midwives running and starting birthing centers to serve their communities such as Uzazi Village in Kansas City, Jamaa Birth in St. Louis, Community Birth Center in Minnesota, the San Antonio Nurse Midwife Birth and Wellness Center, Birth Detroit, Choices in Memphis and Abide Women’s Health Services in Dallas, among others.
Changing Woman Initiative is a nonprofit organization seeking to renew and reclaim Indigenous sovereignty of women’s medicine to promote reproductive wellness. Founded by a Navajo nurse midwife, Nicolle Gonzales, Changing Woman Initiative is aiming to address Native American maternal health disparities, as well as preterm birth, gestational diabetes and low birth weight babies. In 2020, there was an exciting development in the area of Black and brown led birth centers with the creation of a new nonprofit called Birth Center Equity.
This nonprofit was launched in 2020 in the early weeks of the COVID-19 pandemic to support established and emerging birth centers led by Black, Indigenous and other people of color to raise funds and provide capital so that these birth centers could open and stay open. In their first eight months alone, the Birth Center Equity nonprofit, distributed $100,000 directly to 15 community birth centers led by Black, Indigenous and other people of color through a COVID-19 rapid response fund, and then went on to distribute another $250,000 to 25 community birth centers led by Black, Indigenous and people of color to support their operations.
You can learn more about their work at birthcenterequity.org.
We should also celebrate and acknowledge the many Black midwives, Indigenous midwives, and other midwives of color who have survived, advocated, and continue to advocate for birth equity and justice within their national organizations, even while being censored and excluded. I have witnessed in awe the advocacy efforts of Dr. Michelle Drew and Dr. Mimi Niles, both certified nurse midwives, nurse midwives Ms. Patricia Loftman and Ms. Helena Grant, and many others.
In March 2021, the American College of Nurse-Midwives Board of Directors approved and released a Truth and Reconciliation Resolution acknowledging their racist history and the harm that they’ve caused through denial, gaslighting, censorship and exclusion, and acknowledging that until very recently, the historical facts and legacies of racism in their organization were actively denied, although they have yet to make reparations and the organization is only in the very beginnings of its anti racism journey.
This conversation would not be happening without the hard work of the past Leadership of the Midwives of Color Committee. The Truth and Reconciliation Task Force was made up of representatives from the Ethics Committee, Caucus of Black midwives for Reproductive Justice and Birth Equity, DEIB Committee and Midwives of Color Committee.
Here at Evidence Based Birth®, we would also like to honor and celebrate the elder midwives who have transitioned from elders to ancestors over the past year, including but not limited to Claudia Booker, Afua Hassan, Althea Harris, and Nonkululeko Tyemba.
I’d encourage you to watch a video published by Nicole Deggins, certified nurse midwife on her Sista Midwife Instagram page, a video honoring these elders and talking about how we should celebrate their resilience and begin to change the dialogue to focus on healing, joy and love and honoring our elders and ancestors. The work they have done and completed and passed on is so important and life changing.
I’ve talked about the shortage of midwives and the data on the shortage of Black and Indigenous midwives in the US.
Now let’s talk about why midwifery care is so important and why we need more midwives, and more midwives of color. Research studies on midwifery care often focus on the midwife-led model of care. In the midwife-led model of care, pregnancy and birth are viewed as life events. Family-centered care is the norm and care is holistic in which midwives care for the physical, psychological, spiritual and social wellbeing of their clients. The midwife-led model of care also includes continuous support during labor.
Midwife-led model of care includes individualized teaching and counseling, continued support during the postpartum months, minimal use of interventions, and identification and referral of women with complications. In midwife-led care, the midwife is the lead professional in the planning, organization and delivery of care given to someone from their initial visit to the postpartum period. This means they are not supervised by doctors, but instead they are the lead professionals in the midwife-led model.
In some countries, midwives can only care for people with uncomplicated pregnancies. While in other countries, midwives provide care to everyone who’s pregnant, including those with complications in collaboration with their medical colleagues. Many research studies on the midwife-led model of care compare it to either the obstetrician-led model of care or the shared model of care.
In the obstetrician-led model of care, obstetricians provide prenatal care, and they are present for the moment of the birth, although the person who is present at the birth is not necessarily the one who provided the prenatal care. In this OB-led model of care nurses are the one primarily providing care during and after labor. There’s an emphasis in the OB-led model of care of pathology instead of normalcy. These are skilled surgeons who are experts in disease and managing medically complicated pregnancies and births.
There’s an emphasis on testing and interventions, and generally, laboring people are treated as high risk until proven otherwise, which unfortunately can only be proven in retrospect. Treatment tends to be active rather than expected. This may be ideal for the small percentage of people who need such care, but detrimental to the majority of people for whom active management increases risks. So that’s the midwifery model of care and the obstetrician led model of care.
There’s also something called the shared model of care in research studies, where at various points during pregnancy and labor, responsibility for care can shift to different provider types. For example, you are in the shared model of care if you were seeing a midwife in a physician owned and physician managed practice. A Cochrane review on the evidence on midwifery-led care was updated most recently in 2016.
This review was published by Sandall et al., and included 15 randomized control trials involving nearly 18,000 women. The randomized controlled trials were comparing midwifery led care to either the shared and, or medical model. Eight of the 15 studies compared midwife-led care to shared care. Three studies compared midwife-led with medical lead, and three studies compared midwife-led with shared or medical-led care. The studies were carried out in Australia, Canada, Ireland and the United Kingdom.
It’s important to note that in most of the included trials of this Cochrane review, some or all of the women in the control groups or the medical groups actually received care from midwives as well. The difference in these control groups or medical or shared groups, was that the midwives were supervised by physicians or they shared their client caseload with physicians. This means that there was a crossover effect in that midwives were providing care for people in both groups, but the midwife-led care group only had care from midwives and less people needed to be referred for physician care.
In eight of the 15 studies, women were classified as being at low risk for complications and in six studies, there was a combination of both high and low risk pregnant people. The midwifery-led model care births took place in home like settings in four studies. In the rest of the studies, the care during labor took place in hospitals. For the most part, the studies were judged by the Cochrane reviewers to be at low risk for bias, with the exception of the fact that obviously you couldn’t blind or mask people to know which arm of the study they were in.
So you knew if you were getting care from a midwife or a physician. The Cochrane reviewers found that for midwife-led care versus all the other models, women were less likely to experience needing an epidural or spinal, needing an instrumental birth, preterm birth, as well as a combined measure of any fetal loss or neonatal death. There was high quality evidence that the risk of having a preterm birth in the midwife-led model of care was reduced by 24%.
They also saw that the midwife-led care groups had an increase in spontaneous vaginal birth, compared to all the other models. They found no difference between midwife-led care versus all the other models and overall cesarean rates and intact perineum rates. In the midwife-led care groups, there was a decrease in having the waters artificially broken, a decrease in the use of episiotomy and a decrease in the risk of losing your baby before 24 weeks or experiencing a newborn death.
There was also an increase in the midwife-led groups have longer labors, attendance by a known provider and satisfaction with their care, as well as no use of analgesia. So in other words, the midwife-led care groups were less likely to have any pain medications, their labors were longer on average, and they were more likely to have somebody there at the birth who they knew. Comparing the midwife-led care groups versus all the other models, there was no difference between groups in the rate of labor induction or augmentation with pitocin, postpartum hemorrhage, breastfeeding initiation, low birth weight infants, low Apgar scores or NICU admission.
There was also no difference in fetal loss at 24 weeks or later. In other words, midwifery-led models of care lower the chances of miscarriage and early stillbirth, which to me is really compelling because often people are told, “Well, there’s nothing you can do to lower your risk of miscarriage. Miscarriage just happens.” But in these studies, when people were randomly assigned, like flipping a coin, to either receive care from a midwife-led team or from any other model of care, you had significantly lower miscarriage rates in the midwife-led care groups. There’s something that midwives are doing that are improving outcomes, that are lowering miscarriage rates, as well as lowering the risk of preterm birth.
This means that midwife-led care versus all the other types of models of care results in an improvement in some birth outcomes, and also saves fetal lives with no adverse effects for newborns. It’s likely that the results would have been stronger in favor of midwives, but many of the women in the control groups also received care from midwives. There was a little bit of a crossover effect. All the studies had different ways of measuring satisfaction, so it’s difficult to combine their results.
In one study, women who had midwives reported a more positive experience of pain overall, and more often reported feeling very proud of themselves. Women in the midwifery-led groups also felt more in control and more able to cope physically and emotionally. All six of the studies that looked at cost savings found that midwifery-led care saved money in comparison with medical-led care.
You might be wondering, why is there a decrease in miscarriage rates and preterm birth rates with midwives? Well, researchers don’t really know why because midwifery-led care is a complex intervention, but it’s possible that the increased emotional support and the focus on holistic care, as well as the increased nutritional support and counseling that midwives provide may have an impact on early pregnancy loss.
So that’s the data from the randomized trials when they’re all combined together. What about the real life effect of midwives? Well multiple observational studies have found lower rates of interventions with midwifery care. We can look at the American College of Nurse-Midwives annual benchmarking report from 2018 to get a snapshot of the type of results that people who choose midwifery care as opposed to being randomly assigned receive.
You have to keep in mind that midwifery care in the United States is not typically midwifery-led. Often nurse midwives who practice in hospitals are overseen or supervised or working in a physician-led clinic or practice. So these results reflect a slightly different model of nurse midwifery care in the United States, but the data from 2018 showed that with certified nurse midwives, the cesarean rate was 17.2%. The VBAC success rate was 78.6%, inductions of labor were 21.3%. The intact perineum rate, meaning you didn’t have any tears or need for stitches, was 46.4%.
The episiotomy rate was 1.9%, which is very low. The preterm birth rate is 3.6%, which is also very low, and the breastfeeding rate at six weeks was 92%. In 2014, Cheyney et al., published an observational study about home birth midwife outcomes. They included 16,924 people who plan to home birth with a midwife at the onset of labor. Most of the women in this study, 79% were cared for by certified professional midwives, and these data were collected between 2004 and 2009 in the US.
Their outcomes included cesarean rate of 5.2%, an intact perineum rate, meaning no tears or need of stitches, 49%, maternal transfer rate, 11%, newborn transfer rate to the hospital of 1% and the most common reasons for transfer were prolonged labor in need for pain relief. The death rate for babies during labor, and in the first month after life, excluding high risk births was 1.61 per 1,000 overall. That number did go up with higher risk conditions.
One of the problems in the United States as well as in other countries is how well midwives are integrated across the country. In 2018, Vedam at al published a research article called “Mapping Integration of Midwives Across the United States: Impact on Access, Equity and Outcomes”. In conducting this study, an interdisciplinary task force developed a midwifery integration report card.
They measured a variety of factors for each state in the US, including but not limited to, whether or not midwives are prohibited, allowed, unregulated or licensed, if there are statutory limitations that restrict midwifery practice, if consultation with physicians is required by law, and if so, whether or not physician consultation is easy or difficult to access, if midwives can be reimbursed by Medicaid without challenges, and if midwives have prescription writing authority.
A team of 92 state and national regulatory experts then rated each state and gave them a score. They then compared the scores to outcomes in each state. The researchers found that with midwifery integration, when there are higher scores of midwives being well integrated into the state, there are more midwives. So when the regulatory system is favorable, you see more midwives. There also higher rates of spontaneous vaginal birth, VBAC and breastfeeding and lower rates of obstetric interventions, preterm birth and newborn death, both overall rates and race specific rates.
If you go to birthplacelab.org/maps, you can view the visual results of this really fascinating study the one I’ve been talking about by Vedam et al., on midwifery integration. There’s a map of the United States and the darker purple states have the highest rates of integration. Unfortunately, even the states with the highest level of midwifery integration only scored 62% out of a maximum score of 100% when researchers were rating each state.
The 10 states with the lowest midway free integration scores were North Carolina, Alabama, South Dakota, Ohio, Mississippi, Kansas, Nebraska, Oklahoma, Illinois, Iowa and Kentucky. On the other hand, the 10 states with the highest midwifery integration scores or the best scores were Washington State, New Mexico, Oregon, New Jersey, New York, Rhode Island, Arizona, Montana, Idaho and Utah.
You can run the maps a variety of ways to look at different visual graphics at birthplacelab.org/maps, and you can do different overlays to see how midwifery integration compares with other measures of health in the states such as newborn mortality, physiologic birth, VBAC, premature birth, and more. When you run these maps, it’s clear that the states with the highest levels of midwifery integration tend to have the better health scores for their population. Whereas the states with the lowest rates of midwifery integration tend to have the highest rates of newborn mortality, and the lowest rates of breastfeeding, giving a really compelling visual rationale for why we need better integration and more access to midwives in the United States.
So do you know how is access to midwifery care in your community? Are midwives easy to access? Do you live in a part of the world where anybody and everybody has a midwife, or do you live in a part of the world where there are very few midwives, and it’s difficult to access their care or their care is tightly restricted, preventing them from practicing to their fullest scope.
It’s interesting how even within a country, access to midwifery care can vary depending on where you are in that country. For example, midwives support 10.8% of the births in Canada, when looking at data from 2016, and 2017, but the rates of midwifery led birth vary from province to province to territory. Currently, British Columbia leads the country in the highest percentage of midwifery-led births at 22.4% and Ontario leads in the total number of midwifery-led births, more than 23,000 per year.
However, other provinces have much lower rates of midwifery attended births such as 4.2% and 5.5%. In the US, there are some areas of the country where it is easier to access midwives although they’re still not enough midwives for those states. Alaska leads the country and the highest percentage of midwifery attended births at 34%. New Mexico is next highest at 28%, tied with Vermont at 28%, followed by Oregon at 23% and New Hampshire with 22%. On the opposite end of the spectrum, many states in the south and southeast where midwifery integration scores are extremely low and it’s very difficult to practice as a midwife are much lower.
Texas has a midwifery attended birth rate of 4.4%. Louisiana, it’s 3%, Mississippi 2%, Alabama and Arkansas are tied for the lowest rates of midwifery attended births in the country at only 1% of births attended by midwives. In 2020, I gave a presentation to Louisiana birth workers about the evidence on midwifery specific to Louisiana and I did some reading about the history of midwifery in Louisiana. I found that in the year 1915, so a little over 100 years ago, 85% of births in New Orleans were attended by midwives, with 300 midwives working in the parish of Orleans alone.
Back then, midwives crossed the spectrum of ethnic groups in Louisiana, from English speaking, African American midwives, to French speaking Cajun and Black Creole midwives to Native American midwives to a small number of white Anglo midwives. Today, midwifery care in Louisiana has one of the lowest percentages of midwife attended births. It’s an extremely oppressive practice environment for midwives, very difficult for them to practice. The vast majority of births in Louisiana are attended by physicians, and there were only 173 home births in the whole state and 51 freestanding birth center birth in the whole state in the year 2017.
This is coupled with some of the worst health outcomes in the entire country. They have one of the highest preterm birth rates in the United States at 14%, much higher than the US average of 9.6%. Rates of infant mortality in Louisiana are also much higher than the US average, and the breastfeeding rates in Louisiana are some of the lowest in the country as well, with only 67% of infant’s ever having any breast milk. Sadly, maternal mortality rates in Louisiana are also some of the highest in the United States.
The maternal mortality rate in Louisiana is 44.8 per 100,000 mothers, which is more than double the maternal mortality rate in the United States of 20.7 per 100,000. When you look at race specific rates, Black women in Louisiana experienced maternal mortality rate of 73 per 100,000 compared to 27 per 100,000 for white women. That’s only looking at maternal deaths during or within 42 days after giving birth. Rates are even higher for pregnancy related deaths, which includes the entire first year postpartum.
Only recently has the government been tracking and analyzing maternal mortality in Louisiana. About half of the maternal deaths in Louisiana are thought to be preventable. The geographic areas with the highest rates of maternal death were the Southwest Louisiana Lake Charles area, the central Louisiana Alexandria area and the North Shore area. Whenever we talk about racial disparities, we have to be clear that it’s not race itself that leads to racial disparities.
Racial health disparities are due to racism in all of its forms, including the effects of prejudice and institutional and systemic racism. Racism causes acute stress from specific incidents, and chronic stress from a lifetime of exposure. Racism in the healthcare fields is also known to contribute to disparities in maternal mortality. Researchers have found that health care providers are less likely to listen to Black women, and at least twice as likely to ignore their requests for help or fail to respond to their requests for help in a reasonable amount of time.
Vedam et al., also published research in 2019, about mistreatment in birth. This was called The Giving Voice to Mothers study, and they studied more than 2,000 people who gave birth between 2010 and 2016. They intentionally recruited people from traditionally marginalized group, and over-sampled those who had community births at home and birth centers. They found that one in six women or 17% experienced one or more episodes of mistreatment. However, Indigenous, Hispanic and Black woman were at least twice as likely to experience mistreatment.
Twice as many Hispanic and Indigenous women as compared to white women reported that health care providers shouted at them or scolded them. Likewise, Black women, Hispanic women, Asian and Indigenous women were twice as likely as white women to report that a health care provider ignored them, refused their requests for help, or failed to respond to requests for help in a reasonable amount of time. Giving birth in a community setting lowered the risk of experiencing mistreatment.
Among women of color who gave birth at homes or birth centers, only 6.6% reported any mistreatment compared to 34%, or one in three who gave birth in hospital settings who experienced mistreatment. These data show that midwifery care matters. People of color are less likely to experience mistreatment when they receive care from midwives, although obviously it can still happen with midwives as well because midwifery care is not immune from the effects of racism.
Evidence-based solutions to mitigating racial disparities and pregnancy outcomes include doula support and midwife-led models of care. For example, the innovative JJ Way maternity care model founded by Black midwife Jennie Joseph, who is also the founder of Commonsense Childbirth School of Midwifery. This JJ Way model effectively eliminates racial disparities in preterm birth outcomes is documented in a research study published by Joseph’s and Brown in 2017.
Jennie Joseph’s comprehensive, easy access clinic ensures that everyone who comes to that clinic receives care. No one is turned away because of lack of ability to pay. Clinicians develop relationships with clients and bond through mutual respect and education. This is just one example of the fact that there are solutions to racial disparities and that Black birth workers know the solutions and they are saving lives and yet Black birth workers run up against many barriers.
For example, one of the elements of collaborative practice which is essential to midwifery care, being able to collaborate with other professionals and medical providers, so you have to be able to practice collaboratively. Collaborative practice is defined by the elements of respect, trust, shared decision making, partnerships and effective communication, but midwives face many barriers to safe collaboration. They may have different perspectives than their medical colleagues.
There are many regulatory requirements such as outdated requirements that midwives be, “supervised by physicians who want nothing to do with them.” Educational programs lack interprofessional education. So doctors and midwives don’t interact with each other while their students are in training. There’s a strict power hierarchy in which medical providers have lots of power and midwives may have very little given to them.
There’s also a cultural need to “control deliveries,” and control birthing women. Medical staff may see birth is scary or risky and approach it with a lot of fear, while midwives tend to approach it more with confidence and an attitude of normalcy. There’s also a long history of prejudice and paternalism against midwives that dates back to the early 1900s, mistrust or disdain of midwives, and of course, racism faced by midwives of color.
So what are some solutions to overcoming these barriers so that we can have more midwives, and we can have better access to life saving midwifery care. First of all, I think we need to educate our students, residents, doctors, nurses and others about the history of midwifery, and medicine and nursing’s role in oppressing midwives. If we don’t understand our history, we can’t understand our current environment. There needs to be a cultural change towards respect and trust and collaboration with midwives.
Legislation needs to be changed where it’s oppressive. We need an interprofessional education, we need more physicians to be educated alongside midwives. For example, research shows that when residents train underneath midwives, that they gain a new respect for midwifery care and learn a whole bunch of skills that they wouldn’t have otherwise learned, especially with regards to physiologic birth. And almost all the physicians I know who are truly supportive of their midwifery colleagues came to that through their training as medical students or residents or a personal experience with a midwife.
So creating these interprofessional education opportunities for physicians is critical. We need to address the racism that is built into our educational and healthcare institutions, and there’s a huge need to increase access to midwifery school and supportive preceptorships for student midwives of color. There are many national organizations in the United States that are leading the way in these efforts. Melanatedmidwives.org, the National Black Midwives Alliance, the Black Mamas Matter Association, the National Birth Equity Collaborative, the Southern Birth Justice Network, Sister Song, and more.
We’ve tried to list as many of these organizations as we can at our birth justice page at evidencebasedbirth.com/birthjustice, and encourage you to follow at least one of these national organizations and support their work either by following what they do, making donations when you can, or subscribing to their email newsletters. I’d like to give a particular shout out to organizations such as Melanated Midwives.
They’re supporting the next generation of midwives of color. They’re committed to growing the number of Black and Brown midwives through raising funds to provide scholarships for these students, and to provide mentorship and guidance as students graduate. There are also many locally based birth justice organizations that are doing the work in their communities and we list those locally as well at evidencebasedbirth.com/birthjustice.
So today, on the International Day of the Midwife, I want to end by thanking and celebrating the work that midwives are doing around the world. Midwives are literally saving lives. They’re educating communities and empowering their clients during the critical childbearing years. They’re improving outcomes, they’re improving the health of their communities, and continue to do so even amidst the greatest challenges and barriers.
We’re thankful for the resilience of our midwives. We celebrate you, and we are grateful to you. Thank you. Thank you. Thank you. All right, everybody. That concludes this episode on the Evidence on Midwifery Care. I know it was a bit heavy at times, but I also know it was an important conversation to have. I’d encourage you to take this information and think what’s one thing you learned that you want to take away from this podcast episode?
What’s one thing that struck you or that you’re just going to remember and pass on that bit of knowledge to other people? Also, if you think this information was important, share it. We need to spread the word about the power of midwives and the evidence base behind their care. Thanks, everyone, and I’ll see you next week. Bye.
This podcast episode was brought to you by the book, Babies Are Not Pizzas: They’re Born, Not Delivered! Babies Are Not Pizzas is a memoir that tells a story of how I navigated a broken healthcare system and uncovered how I could still evidence based care.
In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover and audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.
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