Deciding on a healthcare provider during pregnancy is an important decision for parents-to-be. While delivering in a hospital, with an OB/GYN is the most common choice, many families are choosing midwife care.
Regulations on midwife licensing and practice differ from state to state. However, a recent research study ranked each state, in a "report card" kind of review. States with less restrictive laws concerning midwifery had better marks for their low rates of birth outcomes like prematurity, cesareans, and newborn deaths.
The study is the first research work to investigate how midwife care impacts birth outcomes. Since every state has a combination of hospital care, OB/GYN care, and midwives, the researchers dubbed the midwife role in the healthcare market as "midwifery integration," and in states where it was highest, for example, Washington and Oregon, there were much better results in childbirth outcomes. At the other end of the spectrum were states with lower rates of midwife integration, mostly in the South and the Midwest. These states had higher rates of poor outcomes, including newborn death.
Melissa Cheyney, a licensed midwife, medical anthropologist and associate professor in Oregon State University's College of Liberal Arts, was a co-author of the study. She explained, "Our findings suggest that in states where families have greater access to midwifery care that is well integrated into the maternity system, mothers and babies tend to experience improved outcomes. The converse was also demonstrated; where integration of midwives is poorer, so are outcomes."
Since the study was not a controlled clinical trial, but rather a survey of health data, the team could make no conclusions as to cause and effect. There was a strong statistical association between readily available midwifery care and lower rates of C-sections, premature births, and newborn and maternal deaths, but there are other factors that impact birth outcomes and choice of care. While not a medical issue, race is part of the picture. The study results show that African American women have a higher number of adverse outcomes, despite the fact that there are fewer African American mothers than white mothers. The numbers in the study did show, however, that midwifery care accounted for nearly 12% of the better outcomes, nationwide.
Team lead for the study, which included health policy researchers and epidemiology experts, was Saraswathi Vedam, an associate professor in the Department of Family Practice at the University of British Columbia. "In communities in the U.S. that are underserved -- where the health system is often stretched thin -- this study suggests that expanding access to midwifery is a critical strategy for improving maternal and neonatal health outcomes."
So how many births in the United States involve a midwife? The estimates are that about 10% of births involve a midwife on the care team. That's much lower than other countries, where the rate of midwife-attended births is about 50% or greater. The lower rate is likely due to the different rules and regulations each state has for home births, midwife licensing, prescribing authority and the number of midwives in practice. Medicaid and insurance reimbursement varies as well; patients who do not have midwife coverage are not always able to choose that option. In countries with higher rates of midwife care, similar research also showed better outcomes for births attended by midwives.
Coming up with the scores for the midwife integration of each state was based on a set of 50 criteria that included midwife availability, access to major medical centers and acceptance by the medical community, including OB/GYNs and labor and delivery nurses.
The state of Washington took the top spot with an integration score of 61 out of 100. New Mexico and Oregon were close behind with scores of 59 9and 58 respectively. The lowest scoring state was North Carolina which came in at 17. A complete list of the rankings can be found here.