Midwives matter now more than ever. This is the compelling bottom line of two major new publications released in recent months: The Lancet's June 2014 Series on Midwifery and State of the World's Midwifery 2014 (SoWMy), coordinated by the United Nations Population Fund, the International Confederation of Midwives, and the World Health Organization.
The Lancet Series has received some attention, including on this blog, but the less visible SoWMy is no less groundbreaking. Over 200+ pages, SoWMy lays out compelling data on women's health globally and a plan for meeting women's fundamental health care needs in 75 "countdown" countries with the highest rates of maternal and newborn deaths and stillbirths. SoWMy also provides an important lens for understanding critical challenges we face here in the United States.
SoWMy argues convincingly that a fully enabled midwifery workforce is the most important step in creating a health system that works well for women and newborns. In the Foreword, United Nations Secretary-General Ban Ki-moon states that
"Every year, more governments, professional associations and other partners are acting on the evidence that midwifery can dramatically accelerate progress on sexual, reproductive, maternal and newborn health and universal health coverage."
Midwifery is a best buy, asserts SoWMy.
"In terms of lives saved and costs of caesarean sections avoided, [midwives are] a best buy in primary health care."
Investing in the education of midwives yields an impressive 16-fold return on investment (ROI) and allows other health care workers to focus on other health needs. The Lancet's Series on Midwifery puts midwifery's ROI on par with vaccination.
We clearly aren't capturing that ROI in the US. Instead, we're in a vicious cycle in which our high-tech approach has led to the most expensive maternity care in the world, without high-quality outcomes to show for it. Data recently made available by Eugene Declercq of the Boston University School of Public Health shows that among industrialized countries with 100,000 or more births, the US has the highest neonatal mortality rate and the fourth highest maternal mortality rate.
The US also has a well-documented shortage of maternity care providers--a gap that could be filled by midwives. According to a 2011 study by the American College of Obstetricians and Gynecologists, 50% of US counties do not have an ob-gyn, and more than half of women living in rural communities are more than 30 minutes away from a hospital offering perinatal services.
The US spends $15 billion annually on graduate medical education for physicians. In fiscal year 2014, spending on nurse education programs was less than 1/60th of that figure, or just under $224 million. In 2012, there were approximately 80,000 medical students in the US, but more than 395,000 nursing students. Our investment strategy in health care workforce development is severely imbalanced, even when accounting for a difference in the costs of medical and nursing education. A very small piece of our meager investment in nursing education makes it to midwifery students.
Most US midwives are registered nurses with a graduate education in midwifery who can offer access to a wide range of primary health care services. They practice in hospitals, birth centers, and homes. The profession's philosophy is based on skilled, compassionate care that respects a woman's natural physiology from puberty through birth, and menopause. Midwives use specific techniques and approaches that foster a woman's innate abilities and rely less on medical interventions, all of which carry risks.
US-based research shows that for the vast majority of women who are at low risk of pregnancy complications, care provided by certified nurse-midwives is as safe and in some cases safer than care provided by physicians. The 2011 Systematic Review of Advanced Practices Nurse Outcomes included 15 studies comparing cesarean rates. Women cared for by CNMs had significantly lower cesarean rates than women cared for by physicians in comparable populations.
Despite all this, US midwives battle ongoing misconceptions in the general public as well as among other health care providers and policymakers, and antiquated state and federal laws prevent them from providing the full scope of care they are qualified to deliver. Even in states where laws or regulations are not restrictive, hospital bylaws often tie their hands. Midwives and advanced practice nurses working in hospitals often live in a pre-suffrage world in which they are not permitted to be on a hospital's medical staff or vote on issues before the staff. They therefore have no say in the very bylaws that dictate what they can do.
In contrast, most European women receive care from midwives who are fully integrated into the health care system--and they experience far better maternal and infant health outcomes than women in the US at a much lower, more sustainable cost.
SoWMy nails it when it asserts that
"Legislation, regulation and licensing of midwifery allow midwives to provide the high-quality care they are educated to deliver and thus protects women's health."
The solutions are known--now we need to run with them. In order for US women to have access to midwives who are educated and able to provide high-quality, high-value care, a workforce transformation must take place. We need a government willing to invest in women. Passing legislation like H.R. 4385 would at least get us started with tracking maternity care shortage areas so we can tackle them.
To get that, we need women like you and me to demand better, safer, and evidence-based care. We need families to insist on the human right to skilled, compassionate support through life's most important milestones. But don't wait for an act of Congress. If you are preparing for birth or planning to have children someday, I urge you to visit www.ourmomentoftruth.com to learn about your options. Educating yourself and those around you will maximize your chance for a normal, healthy birth. It's time to ensure every US woman has access to safe, evidence-based maternity care.