Currently, midwives attend only about nine percent of the nearly 4 million U.S. births annually. While this is likely an underestimate since the legality of midwife-attended births varies across states and some women may not report their midwives’ presence, it is clear the share of midwife-attended births in the United States is much lower than in many developed nations. In the U.K., for example, midwives deliver approximately half of all babies and rates can be even higher than this in some Nordic countries.
Ellerie Weber, MBA, PhD
My research as a health economist, and my experience as a mother, convinces me that we should increase the participation of midwives in the birthing process. I believe midwives were partly to thank for my own positive birth outcomes because of their strong emphasis on ‘normalcy’ during my prenatal care and births. I’d like to share my stories as an example.
My Birthing Experiences with Midwives
My partner and I chose to deliver our three babies under the care of certified nurse midwives (CNMs). The first birth was nerve-racking and difficult labor, apparently because of the baby’s occiput (or sunnyside-up) and asynclitic (neck-kinked) position. My memories are freeze-frame moments, such as when our midwife told us the baby’s heartbeat was decelerating during contractions, or when my labor stalled and they called in a physician. And, of course, when the baby was born (with the help of IV fluids and oxygen), 19 hours after my water broke, and 15 hours after the contractions had started.
With the second, there was a lot of waiting followed by a quick birth with some complications. My water broke one evening, but contractions didn’t begin until late-next morning and our second son was born less than an hour later. I remember the midwife entering the room, listening to one contraction, and telling me the baby was coming. The baby was born grey and limp, the umbilical cord wrapped tightly around his neck. His one-minute Apgar score was a five—which is not good—and the five-minute score was a nine—much better.
Labor for baby three began in the middle of the night and our third son was born around noon, a more textbook birth. However, with this one, my water never broke. The baby was born “en caul,” from the Latin for “in the veil”, meaning the amniotic sac remained intact during his entire birth. This is apparently very rare, and as such, has been associated with many superstitions and folklore about a baby’s temperament and gifts.
A Growing Recognition of Midwifery in the U.S.
Within-country studies from non-US based populations unequivocally show that women who had midwife-led continuity of care models were less likely to experience epidurals, instrument-assistant birth (such as forceps, or vacuum-assisted delivery), preterm birth less than 37 weeks, as well as less fetal loss and neonatal death. A small but growing U.S. body of research also shows positive health outcomes associated with midwife-attended births.
A recent study by Laura Attanasio, PhD, and Katy Kozhimannil, PhD, MPA, found that women delivering in hospitals with more midwife-attended births had lower odds of Cesarean section and of receiving an episiotomy, although no reduced odds of labor induction or severe maternal morbidity. Another recent study by Molly Altman, PhD, MPH, CNM, and colleagues found that medically low-risk women delivering with CNM-led care in hospitals had lower use of labor and birth interventions, including Cesarean and vacuum-assisted delivery, epidural anesthesia, labor induction, and cervical ripening compared to similar low-risk patients with OB-GYN-led care. Midwife-led mothers also had shorter maternal duration of stay and lower overall costs compared to similar women having OB/GYN-led care. Moms and babies’ outcomes were comparable across groups.
Here at Mount Sinai, too, midwives work alongside obstetricians and are seen as an integral part of the care offered to women. In 2020, for example, nine midwives delivered more than 450 babies at The Mount Sinai Hospital, and another nine worked delivering babies at Mount Sinai West.
Challenging the ‘Culture of Normalcy’
Birth stories are amazing. Ask a mother about her birthing experience and you will not be disappointed. Each birth is dramatic and encompasses many emotions—excitement, fear, happiness, pain, love, comedy, suspense, beauty, and sometimes unfortunately, sadness. Listening to many stories, it becomes clear that the similarity of births actually lies in their differences: insofar as each story is guaranteed to differ in its details, to have something unexpected occur, every birth could be considered normal.
In a joint commentary for Obstetrics & Gynecology, Chitra Akileswaran, MD, MBA, and midwife Margaret Hutchison, CNM, MSN, discuss that the ‘culture of normalcy’ is currently missing from the ethos of the U.S. health care system. Modern obstetrics was developed to avoid the worst possible outcomes–that is, death of moms or babies–and has indeed successfully reduced the morbidity and mortality of childbirth. However, Dr. Akileswaran and Ms. Hutchison argue that perhaps the pendulum has swung too far. Our fear of avoiding bad outcomes may now be preventing us from supporting the normal processes of childbirth, resulting in undue intervention and potentially causing harm.
So how can we meet the needs of most healthy, low-risk pregnant women outside the medical model of childbirth, albeit still gratefully accessing medical tools when necessary? Increasing the participation and contributions of midwives in the United States could re-establish this ‘culture of normalcy.’ Midwife participation could be manifested by improving reimbursement for midwives, passing state licensure laws to increase both the scope of care midwives can provide and their autonomy from physicians, increasing physician exposure during training to midwife-led care models, growing the midwife workforce, and increasing the presence of midwives in hospitals.
Regardless of how we get there, it is important to remember, as Dr. Akileswaran and Ms. Hutchison write, that “striking the balance between averting poor outcomes and normalcy compels us to make room at the table for both obstetricians and midwives.”
Ellerie Weber, PhD, MBA, is a member of the Blavatnik Family Women’s Health Research Institute and her research focuses on economic issues of cost, pricing and competition in the health industry. She is an Assistant Professor at the Icahn School of Medicine at Mount Sinai, and affiliated with the University of Texas Health Science Center at Houston School of Public Health.