Midwives often come up in conversations of home births and even “Goop” moms, often deemed problematic. But they’re fast becoming an effective primary and reproductive health care option as women’s access to healthcare (especially if they’re low-income) is rolled back.
The rising profile and respectability of midwives has also sparked debate over whether they can be part of major public health solutions in the United States. But certified nurse-midwives’ and certified midwives’ independent practice within the healthcare system is still limited, varying by state.
“‘Independent’ has become a dirty word,” Lisa Kane Low, president of the American College of Nurse Midwives and associate professor at the University of Michigan’s School of Nursing, said. Powerful organizations such as the American Medical Association, according to Kane Low, “take the word ‘independent’ to mean not within any kind of health care structure that supports interaction and collaboration.”
A first-of-its-kind study published last month in the journal PLOS One found states where midwives are more integrated into the system also reported better maternal care outcomes.
Advocates for “untethering” midwives from physicians say the stigma around “independence” hurts women, especially as physician’s organizations like the American College of Obstetricians and Gynecologists (ACOG) have supported their “full scope, autonomous practice,” as “qualified, accountable providers who work collaboratively with ob-gyns in an integrated maternity care system that promotes seamless access to appropriate care.”
“If a nurse midwife is trained appropriately to provide well woman services or primary care services, we support that,” Dr. Hal Lawrence, ACOG's CEO and EVP, told The Daily Beast. A model of “team-based care,” which ACOG supports, does not mean a doctor must always supervise a midwife.
But doctors and nurses don’t make the legal cut, and the power struggle for midwives has run deep. A century ago, midwives were subordinated as physician specialization grew. Dr. Joseph DeLee, considered the founder of modern obstetrics, declared childbirth a “pathologic process,” introduced forceps, sedatives and episiotomies and denounced midwives as a “relic of barbarism.”
The United States’ attitude toward midwives differs from other developed countries, including Canada, Australia and England, where midwives lead the obstetric system with stronger birth outcomes.
Currently, full supervision requirements in five states—California, Nebraska, North Carolina, South Carolina, and Florida—and partial supervision requirements in dozens of others limit the services midwives can provide, and where they can provide them. This restriction can especially hurt low-income and rural communities, according to Kane Low. In 27 states and D.C., certified nurse-midwives can legally practice without physician supervision.
“Something that always has been a core part of midwifery is going where we are needed,” Sheri Mateo, secretary of the California Nurse-Midwives Association, told The Daily Beast. “More midwives would do that if we weren’t tethered to physicians.” By allowing certified nurse-midwives or certified midwives to practice independently in more areas of the country, ACNM argues, women would have more access to primary and maternal health care.
What people don’t realize is that there are different categories of midwives, who work mostly in hospitals and deliver less than 9 percent of births in the United States. A certified midwife enters an accredited, graduate midwifery education program with background in science and must pass the same national exam as her nurse peers.
“It boils down to who is in control,” said Kane Low, who’s practiced as a CNM for 30 years. “And unfortunately in some states, partially through the lens of the AMA, the idea that you would be independent is turned into somehow you’re going to go rogue.”
A New Public Health Crisis
A doctor shortage is looming, and the U.S. has the highest rate of maternal mortality in the developed world, especially for black women. Meanwhile, employment of nurse-midwives increased by about 23 percent between 2014 and 2016.
More than half of rural U.S. counties lack hospital obstetric services. The Wall Street Journal reported last year that women in rural areas are 64 percent more likely to die in childbirth than in urban areas. “God damnit! Rural areas should only have higher concentrations of Waffle Houses!” the late-night Samantha Bee joked in a skit on the maternal health care crisis in January. “Maternity-care deserts” also rely heavily on Medicaid, a program Republicans have long been promising to gut.
Midwives work with healthy, child-free women to provide birth control, abortions, or routine exams. About 50 percent of CNM’s identify reproductive care and 33 percent identify primary care as regular responsibilities, according to the ACNM.
Critics of midwives’ independent practice, including the AMA, “think we are trying to remove obstetrics,” Holly Smith, health policy co-chair of California Nurse-Midwives Association, said.
Obstetrics include procedures like fetal screening and Caesarean sections. "We feel that we made a lot of progress in making connections with our physician counterparts,” Smith added. “We are attempting to change a law and a culture of care that has been around for decades and permeates the way we think about the best way to care for women during pregnancy and birth.”
A 2014 editorial in the New York Times referenced British research that found midwives delivered safer uncomplicated pregnancies than doctors, and alluded to the “longstanding turf war between obstetricians and midwives.”
“Midwives in general are huge patient advocates, and throughout the health care system, they bump into areas where women are not getting their needs met,” Julia Phillippi, a CNM and assistant professor at Vanderbilt University, told The Daily Beast. Phillippi authored a 2015 paper about this very topic in the Journal of Midwifery and Women’s Health.
“We cost less to pay, we have good outcomes for low-risk women,” Phillippi added. “If you are a health system trying to care for vulnerable women who don't have health insurance, nurse midwives are often a cost-effective option.”
Many women are simply unaware that they can seek primary care from a midwife.
“I worked for years clinically as a midwife. We would say we work ‘full scope’... We had to stay in our lane and do OBGYN care,” Mateo said. “It has varied for midwives across the board, and many times we are not being allowed to function to the top of our education, to the top of our license.”
Some midwives who work under doctors on a regular basis say it’s harmonious and not necessarily reflective of the higher-level politics. But the position of ACNM is that such restrictions create ambiguity around which provider is accountable and how power is distributed on a team—though that might change in the future.
“When you are in the trenches together, we support each other,” Smith, the CNM in California, said. “It doesn't feel like there's a turf war. It feels like we are all working together.”