April 11 marks the beginning of this year’s Black Maternal Health Week—a week of action, awareness-raising, and advocacy to combat the United States’ maternal health crisis, one which puts Black women and birthing people at alarming risk. It is unacceptable that our maternal health outcomes continue to worsen, and it is beyond time that we devote adequate attention and resources to reversing this trend.
Despite the demonstrated benefits of midwifery care, and its historical importance in the care of Black women in particular, midwives have been excluded from the U.S. health care system. In order to reduce inequities in maternal health outcomes—caused by a legacy of structural racism and ongoing discrimination—Black birthing people must have access to community-based care, and midwifery care in particular. This commentary will briefly outline the importance and history of midwifery care in the United States, and recommend policies that would increase equity in access.
Midwifery Care and Its Benefits
The Black maternal health crisis cannot be solved without access to quality, patient-centered, and affirming care—including midwifery care. Midwives, the vast majority of whom in the United States are either certified nurse-midwives (CNMs) or certified midwives (CMs), provide a range of services for women and birthing people throughout the reproductive life course. Notably, midwives are the traditional care providers for pregnant individuals, providing support throughout pregnancies, during birth, and into the postpartum period (and playing a critical role in the global reproductive health workforce). Depending on their level of training, midwives may be trained to attend births in hospital settings alongside physicians, or may provide care in birthing centers or home births, without physicians present.
The midwifery model of care uses a client-centered approach that aims to support individuals before, during, and after birth. Using a holistic framework that takes into account the physical, psychological, and social well-being of the birthing individual, midwives offer hands-on care and seek to reduce unnecessary medical interventions.
When compared to other models of care, midwifery care is associated with higher levels of satisfaction and fewer interventions. In particular, patients associate midwifery care with personalized care, trust, and empowerment.
When compared to other models of care, midwifery care is associated with higher levels of satisfaction and fewer interventions. In particular, patients associate midwifery care with personalized care, trust, and empowerment. Giving birth with the assistance of a midwife can also decrease the odds of cesarean sections, which can improve outcomes for subsequent births; the procedures are associated with increased risks to fertility and adverse birth outcomes for later pregnancies. This is particularly important for Black women, who are at higher risk for receiving cesarean sections, even with low-risk births. Additional research has demonstrated that integration of midwifery care into health systems is associated with positive maternal health outcomes. Furthermore, costs of midwife-assisted births are, on average, lower than obstetric-led care.
These benefits that midwifery care offer are crucial for communities that suffer disproportionately from the burden of maternal mortality and morbidity, particularly Black and Native birthing people.
A History of Exclusion in the United States
The practice of midwifery dates back to the beginning of recorded history, has roots across cultures, and, as it’s practiced in the United States, also has origins in West African traditions brought to the country by enslaved people. Black midwives—including the grand midwives who helped establish the practice in this country—were historically critical in supporting women through childbirth and beyond. Yet Black providers are not well represented in the current midwifery workforce: today, over 90 percent of nurse-midwives in the United States are white. This shift in demographics did not happen by accident: rather, it was the result of systematic exclusion and the medicalization of childbirth.
From the end of the nineteenth century and into the twentieth, the influence of the American Medical Association (AMA)—a professional association and lobbying organization for physicians—grew. The AMA pursued “professional homogenization and increased standards for medical education;” as the field of obstetrics emerged and childbirth was increasingly medicalized, midwives were pushed out from practicing. (It is worth noting, too, that the field of obstetrics and gynecology was built in part on the exploitation of and experimentation on enslaved women.) The medical establishment’s narratives often used racist, sexist, and classist language to discredit the largely Black midwifery workforce. This discriminatory rhetoric accused Black midwives of being dangerous, unprofessional, and unhygenic. To this day, racism persists within the field of midwifery, and highlights the need for diversification of the workforce.
Access to Midwifery Care Today
As a result of this medicalization of maternal care and the move towards hospital-based births, midwifery care has become less common in the United States: today, midwives only attend 10 percent of births nationwide. Given the obstacles that many individuals face in receiving any pregnancy-related care at all, midwifery offers an underutilized model that deserves expanded access. Currently, 2.2 million women of reproductive age in the United States live in maternity deserts (areas without a maternal health provider). Midwives are already meeting some of these needs outside of urban centers: in rural areas—which have been particularly plagued by hospital closures—midwives attend around one-third of all births.
Insurance coverage of midwifery care can be a barrier for potential patients. Despite the benefits of midwifery care, it is often inaccessible to the people who need it most—including Medicaid enrollees. Addressing access within Medicaid is particularly important to eliminating maternal health disparities, because the program finances two-thirds of births to Black women.
Improving access to midwifery care means also improving access to freestanding birth centers: even though midwifery care can be offered in any setting, it is always offered in birth centers. Birth centers offer a holistic approach to care using a midwifery model, and have been shown to have positive outcomes and high levels of patient satisfaction. Medicaid enrollees, however, have less access to birth centers than do privately insured individuals. Inclusion of birth centers and home births in Medicaid programs are both dependent on states, and only half of states cover home deliveries (which may be attended by midwives). Low Medicaid reimbursement rates for birth centers may also limit the number of Medicaid enrollees that centers can accept—these reimbursement rates vary by state and fall well below Medicare rates. In addition, onerous scope of practice and licensing laws can restrict the care that midwives can provide or require physician supervision.
An equitable approach to midwifery care is one in which Medicaid enrollees have access to midwives to the same degree as pregnant people with private insurance, and one in which midwives themselves are reimbursed at a rate that is comparable to other providers.
How We Can Improve Access to Midwives through Policy
This Black Maternal Health Week, there are a number of existing policy proposals to uplift that could address these obstacles to midwifery care. Several legislative proposals would promote equity for both Medicaid enrollees and midwives with Medicaid-financed patients. For instance, the Mama’s First Act, introduced in the 116th Congress by Representative Gwen Moore (D-WI-4), requires Medicaid coverage of not only midwifery services but also doula care.
To ensure that Medicaid enrollees are able to access birth centers and the midwifery care they offer, the Centers for Medicare and Medicaid Services (CMS) should also enforce its earlier guidance to states that at least one birth center is included in each Medicaid managed care plan. Senator Lujan (D-NM) and Representative Katherine Clark (D-MA-5) also introduced the Birth Access Benefiting Improved Essential Facility Services Act (BABIES) Act, which would require CMS to establish a demonstration project to improve freestanding birth center services. In addition, even without further action from Congress, the CMS Innovation Center (CMMI) could use its existing authority to test models that include midwifery care.
Federal policy efforts can also address the expansion and diversification of the perinatal workforce, including midwives. The Midwives for MOMS Act of 2021, introduced by Senator Lujan and Representative Roybal-Allard (D-CA-40), would create grants within the Health Resources and Services Administration to establish or expand midwifery programs. The Perinatal Workforce Act, led by Representative Moore and Senator Baldwin (D-WI)—and part of the Black Maternal Health Momnibus—seeks to grow and diversify the perinatal workforce. Its provisions that were included in the House version of the Build Back Better Act specifically devote funding for training of CNMs; TCF analyses found that these investments would provide tens of thousands maternal health professionals with educational support.
In considering funding, community-based organizations should also be prioritized. These groups, often Black women-led, are already leading efforts to provide Black women and birthing people with patient-centered care. Legislation like the Kira Johnson Act, led by Representative Alma Adams (D-NC-12) and included in the Momnibus, would make important investments in these organizations. Maternal health funding investments, including those from the Perinatal Workforce Act and the Kira Johnson Act, must be included in the final iteration of the social spending package passed through budget reconciliation.
Of course, ensuring access to care also means providing people with health coverage throughout pregnancy and the postpartum period. Regardless of whether a Medicaid enrollee chooses midwifery care, coverage must be provided for a full year postpartum. Extension to one year of Medicaid postpartum coverage must be made mandatory and permanent, building on the important progress of the state option included in the American Rescue Plan Act of 2021.
Increasing access to high-quality, personalized, and holistic care—as offered by the midwifery model of care—is crucial to eliminating disparities in maternal health outcomes. However, midwives, and Black midwives in particular, have been historically excluded from the U.S. health care system. In order to improve Black maternal health outcomes, access to midwifery care must be made widely accessible and affordable for all pregnant people, and this Black Maternal Health Week should serve as a call to action.