Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

Abstract

Poor coordination of care across providers and birth settings has been associated with adverse maternal-newborn outcomes. Research suggests that integration of midwives into regional health systems is a key determinant of optimal maternal-newborn outcomes, yet, to date, the characteristics of an integrated system have not been described, nor linked to health disparities.MethodsOur multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the ‘on the ground’ relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.ResultsMISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.ConclusionThe MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Using the Robson 10‐Group Classification System to Compare Cesarean Birth Utilization Between US Centers With and Without Midwives

“…State‐level health care policy and regulation greatly influence the prevalence and boundaries of midwifery practice . Midwives are an integral part of intrapartum care for many US women, yet the scope and influence of midwifery care in the United States remains limited in many states . Our findings suggest that policies supporting increased integration of midwifery care across the United States, which includes eliminating the systematic barriers to independent midwifery practice, could improve overall cesarean rates and greatly improve rates of VBAC.…”

“…The proportion of midwife‐attended births varies widely by state, ranging from 0.6% to 27%, and may be underreported in state vital statistics . State‐level health care policy and regulation greatly influence the prevalence and boundaries of midwifery practice . Midwives are an integral part of intrapartum care for many US women, yet the scope and influence of midwifery care in the United States remains limited in many states .…”

Midwifery is a vital solution—What is holding back global progress?

“…[1][2][3][4][5][6] We argue that the intersectionality of gender, social, professional, and economic disempowerment, fueled by powerful precedents and perverse incentives, constrains momentum. [1][2][3][4][5][6] We argue that the intersectionality of gender, social, professional, and economic disempowerment, fueled by powerful precedents and perverse incentives, constrains momentum.…”

“…15 Midwives, who are predominantly women, are subject to the same discrimination as other women in their societies. 6,17 Complicating this gender and social inequality is an underlying related professional bias. Many midwives are inadequately remunerated or supported, overwhelmed by workload, and working in situations that expose them to sexual and other forms of violence.…”

Using the Blueprint for Advancing High‐Value Maternity Care for transformative change

“…Nearly half of childbearing women are women of color, yet the clinicians who care for them are disproportionately white. 18,19 Critical steps must be taken to achieve optimal maternity care workforce composition, including enhancing diversity, retaining and optimally deploying obstetricians as active maternity care practitioners, increasing family physician provision of maternity care, expanding the midwifery workforce, achieving the potential of laborists, and developing effective models to ensure access to care in rural and underserved areas. 16,17 There are indications that when midwifery care is less integrated at the state level or when scope of practice laws is more restrictive, maternal and infant outcomes suffer.…”