After pushing for several hours, my patient looks exhausted but happy, clutching her seconds-old newborn to her chest. As I help her put her baby to breast for the first time, she isn’t thinking about anything other than the tiny human blinking up at her.
As well she shouldn’t.
She doesn’t know that this birth would have happened by C-section at most American hospitals, something that would have put her at risk for a host of complications and virtually guaranteed that any future births would also be by C-section. But I do.
As a certified nurse-midwife, I know that my presence, patience, and encouragement during her labor probably made the difference between a vaginal birth and a C-section. A recent study linked midwifery care from hospital-based midwives like me to 30% to 40% lower rates of C-section for low-risk women.
In the United States, about 32% of births occur by C-section, even though the World Health Organization recommends rates not exceed 10% to 15% for optimal maternal and neonatal outcomes. But C-section rates are not the only area in which the U.S. is underperforming.
At 24 deaths per 100,000 live births, its maternal mortality rate is more similar to that of Iran than of economic peers like the United Kingdom or Germany. Preterm birth, a major cause of infant death and lifelong disability, occurs in 1 of 10 births. Seven million women live in maternity care deserts with minimal access to care. Yet with the average cost of maternity care at nearly $19,000, the U.S. spends far more on maternity care than countries with much better outcomes.
The reasons for America’s high-cost, low-quality maternity care are complex. But one rarely acknowledged difference between the U.S. and countries with better outcomes is that they use more midwives. The U.S. has a similar number of OB-GYNs per 1,000 births compared to countries like Britain, the Netherlands, and France. But in those countries, midwives are an integral part of the health care system, outnumbering OB-GYNs 3 to 1.
Why does this model work? A strong midwifery workforce frees up physicians to concentrate on high-risk pregnancies while offering lower-risk pregnant people more personalized care with longer visits and increased psychosocial support, which are typical of the midwifery model of care.
Just as midwifery has been successful abroad, U.S. states with greater midwifery integration into their health care systems have better outcomes, including lower rates of C-sections, preterm births, and neonatal deaths.
So why is the U.S. sitting on a solution that could clearly benefit childbearing families? A host of cultural and historic reasons account for the continued marginalization of midwifery in the U.S.
Sometimes I envy my colleagues across the Atlantic, where “midwife” is a household name that garners respect and admiration. Midwifery is widely accepted by the British public and medical system, with 43 midwives per 1,000 births compared to America’s 4 per 1,000. It barely made the news that Duchess Kate Middleton delivered her babies with midwives. Rather, The Economist mused that Kate’s delivery in a private, luxury maternity suite cost less than the average vaginal birth in the United States.
In the U.S., midwives like me face a different reality. I am frequently asked to explain the difference between a midwife — a licensed health care provider — and a doula — a counselor who provides emotional support and guidance through the childbearing process. I have to defend my education and credentials to people who assume I have no formal training, though becoming a certified nurse-midwife requires a master’s degree, hundreds of hours of clinical training, and board certification.
Midwifery is often written off by the American public as a fringe choice for women who eschew pain medication in labor and plan to give birth at home. While it’s true that most home births are attended by midwives — usually certified professional midwives, who have extensive apprenticeship training — the vast majority of midwife-attended births occur in hospitals, with certified nurse-midwives like me. And women don’t have to choose between a midwife and an epidural. I’ve attended births by people who labored in a tub with aromatherapy and soft music in the background, and by those who got epidurals and watched the Green Bay Packers game.
American midwifery’s public relations problems are deeply rooted in history. A campaign by the American Medical Association in the early 1900’s discredited midwives as quacks. Doctors lobbied to remove midwifery training programs and pass laws making midwifery illegal. Joseph DeLee, an influential early 20th century obstetrician, called midwives a “relic of barbarism.” Sexist and racist attacks painted midwives as dirty, uneducated, and dangerous. By the 1940’s midwifery was virtually eradicated in the United States.
It was preserved, however, in Black communities, whose members were not allowed in many hospitals during segregation. The African American midwife Margaret Charles Smith, whose career attending home births in Alabama spanned several decades, wrote in her autobiography about Black patients being denied access to the hospital even when they had life-threatening complications. Ironically, she was later forbidden from attending home births after it was made illegal. Highly skilled midwives like Smith were forced out of business, leaving Black communities without their traditional caregivers.
Discrimination against midwives is still baked into health care policy. It limits the number of midwives and hamstrings the efforts of existing midwives.
Midwifery training programs are few and underfunded, receiving just a fraction of the funding that medical schools and residency programs get. Universities with midwifery programs mostly depend on volunteer midwives to train students during in-person clinical work without reimbursement, thus limiting the supply of willing preceptors.
Recent interest in increasing capacity for midwifery education led to the Midwives for Moms Act, which was introduced into Congress in 2021. It would provide funding to create or expand education programs with an emphasis on restoring midwifery to underserved areas. Passing this bill is a must if the U.S. is to begin addressing its dearth of midwives.
In my home state and many others, a midwife’s ability to practice legally is contingent upon a physician’s willingness to sign a collaboration agreement. An obvious restraint of trade, laws like this give physicians an opportunity to intentionally exclude midwives from the workforce due to fears about competition. They also create burdensome requirements and potential liability for physicians who would otherwise be willing to work with midwives, disincentivizing collaboration.
Overcoming decades of bias against midwifery won’t be easy, but I see a tipping point on the horizon. At 1 in 10, the number of midwife-attended births in the U.S. is the highest it has been in decades. Women are increasingly choosing midwives, putting pressure on health care systems to respond to the demand by hiring more of them. Healthcare administrators may also notice that, at $116,892 compared to $302,301, the yearly cost of employing a certified nurse-midwife is significantly cheaper than employing an OB-GYN.
Midwifery care cuts cost, improves outcomes, and increases patient satisfaction. The next logical step is to create policies that increase the number of midwives and address barriers to midwifery practice.
I’d love to live in a country where my profession is better understood and more respected. But it’s really not about me. The U.S. needs more midwives because the nation’s subpar birth outcomes and excessive costs are evidence that pregnant people are not getting the care they need most while health care dollars go to waste.
The country has already waited too long: It’s time to call the midwife.
Ann Ledbetter is a certified nurse-midwife at Sixteenth Street Community Health Centers in Milwaukee, Wis., and a member of Wisconsin’s Maternal Mortality Review Team.
