With the increasing awareness of the problems afflicting the American maternity system, many have begun to question whether, at this point, we are too far gone along the path of intervention as standard of care to ever change course. It seems particularly unlikely that change is possible when we continue to apply the same philosophy of care, birth in the same locations, and utilize the same providers. How many generations of doctors will it take before the main tide of opinion favors low intervention and natural options for childbirth. This is because, as profoundly stated by Akileswaran and Hutchinson,¹ “what is missing is a reference point of what is normal; the concept of normalcy is secondary in the medical model of health, in which suspicion of pathology is often the lense for each interaction or decision.”

The midwifery model of care offers that reference point, by beginning with view that pregnancy and childbirth are normal life events. This does not mean midwives believe childbirth is devoid of any danger. That would be a denial of the high rate of maternal mortality (608 in every 100,000 births) observed less than century ago in the United States and still seen in some parts of the world today.² However, the midwifery model of care attempts to find that elusive middle ground of avoiding bad outcomes without subverting the normal process of birth. The manner in which this is done is through the establishment of close personal relationships with patients, which promote a partnership mentality and shared decision making. Noninterference in normal processes and continuous hands-on support of the laboring mother are standard and there is a judicious use of technology and medical interventions. Referral to obstetrics services is employed only when complications arise or a woman is at sufficient risk of a complication. Healthy lifestyle choices are encouraged in order to minimize complications and the physical, psychological, and social well-being of the mother are monitored throughout pregnancy.³

This care philosophy appears to have excellent results. In the most recent Cochrane Review of 15 separate trials, involving 17,674 predominantly low-risk women who were cared for and delivered by certified midwives in a hospital setting, midwife-led care demonstrated multiple advantages over standard physician-led care. Patients cared for by midwives utilized epidurals at a lower rate, had lower rates of operative deliveries and premature birth, and lower rates of perinatal death. Midwifery-led care was also less likely to include episiotomies, pitocin use, and artificial rupture of the membranes or amniotomy. Furthermore, patients cared for by midwives were more satisfied with their care.⁴ A reduction in the risk of cesarean section was not observed in the Cochrane Review, but alternative reviews have also found a decreased rate of cesareans among patients cared for by midwives.⁵ From this data, it seems expanding the availability and utilization of midwives would be a simple way to increase the number of providers applying a low-intervention approach and offer more women a supported natural birth.

Expanding midwifery care also seems like the path of least resistance. Why not direct women to the care providers who already support natural birth to the degree that it forms the basis of their mission statement and care philosophy? Many in the media have come to this same conclusion and a public doctor versus midwife debate has raged in print, social media, and on television. Articles such as “Are Midwives Safer than Doctors?,” “Doctors versus Midwives: The Birth Wars Rage On,” and “Pregnancy Is Way Better Without an OB/GYN,” are just a small sampling of the polarized discussion that has ensued.^6–8 Unfortunately, this has created the impression in the minds of many that midwives are somehow outside of the medical system, rather than operating with a different philosophy within it. It also has presented doctors and midwives as two equivalents that a woman must choose between, rather than presenting the midwifery model of care as something that should be broadly adopted for all low-risk women by doctors and midwives alike. This is problematic because there are a number of challenges preventing the widespread transition of maternity care from doctor to midwife.

Lack of Midwife Accessibility

Many women in the United States who may wish to receive care from a midwife simply do not have that option. According to the American Midwifery Certification Board, as of 2016, there were 11,475 certified nurse midwives and 103 certified midwives in practice, mainly in the hospital setting.⁹ According to the National Association of Certified Professional Midwives, there are an additional 2,454 certified professional midwives also providing care, mainly in the home or birth center setting.¹⁰ Even when the addition of non-nurse midwives, who are not currently supported by the American College of Obstetrician and Gynecologists, are taken into account, there are not enough midwives to provide care for all the low-risk women within the United States who may desire it. In comparison, there are 33,316 practicing obstetricians in the United States as of 2010, which is in itself insufficient to provide care for the number of women requiring it, 49% of whom live in a county without a single obstetrician.¹¹

Besides inadequate numbers of midwives, regulation of midwives also limits their accessibility. Many states require certified nurse midwives to have either direct supervision of a physician or a written collaborative agreement in order to even obtain licensure and many hospitals require collaboration in order to obtain hospital privileges. If a midwife is unable to find a physician in her area who is willing to provide that supervision or collaboration, she is unable to practice. Some states also restrict midwives’ ability to prescribe medications or specifically prohibit even nurse-midwives from attending out-of-hospital births. Furthermore, even if a state does not restrict midwifery practice through licensing limitations, hospitals may use their own discretion when deciding whether or not to grant admitting privileges and few states have laws in place preventing them from discriminating against midwives.

Another accessibility barrier is financial. Insurance companies have been slow to contract with midwives for in-network maternity care or be willing to offer reimbursement for out-of-hospital births. This means many patients desiring midwifery care have been forced to go out-of-network or pay out-of-pocket for services, which is financially prohibitive for many women. The situation has improved with the passage of the Affordable Care Act, which mandated insurance coverage for out-of-hospital birth, but with the future of that law in political jeopardy, many worry that insurance companies will not even be mandated to provide maternity benefits, let alone coverage for midwifery or out-of-hospital birth. Even when insurance companies are willing to reimburse for midwifery care, sometimes that reimbursement is lower than that of physicians. Hence, most midwives find themselves in the same financial struggle obstetricians find themselves in: low reimbursement for the care provided and high liability insurance overhead. They are further financially handicapped by lost reimbursements when they must refer care to an obstetrician due to the development of a complication. Consequently, midwives are often forced to play the numbers game and increase the number of patients they see, limiting their ability to practice according to the midwifery model of care. Many midwifery practices struggle to simply stay afloat.

Obstetricians have dominated the birthing business for so many generations that few American women have a member of their family who was cared for or delivered by a midwife. Most women receive their routine gynecologic care in adolescence and young adulthood from an OB/GYN as well. Consequently, when they become pregnant, few women even think to seek care elsewhere. Most equate doctor-supervised hospital birth with safety and often mistakenly believe midwife care is synonymous with home birth or birth center birth. There is also a misperception that only women who want natural births see midwives and, if a woman plans on an epidural, she should see an obstetrician. While many women come into their first pregnancy with the idea to try and do things as naturally as possible, most are open to an epidural and want the option. Unless they have been exposed to other women who have used midwives or they have received information regarding natural birth and midwives in their childbirth education, it is usually only after their first birth does not go as planned that women begin exploring other options and learning about the medicalization of birth. It will take several generations of increasing percentages of women being cared for by midwives before the majority of women see midwifery care as commonplace and familiar.

There is also a huge barrier of tradition and acceptance to overcome in the medical community. Good midwifery care depends on strong collaboration with obstetricians, as will be discussed. Few obstetricians have ever trained or worked with midwives, so they have not been exposed to their philosophy of care and had the opportunity to grow comfortable with their approach. There are also large numbers of obstetricians with strong biases against midwives, who view them as undertrained and often dangerous in their anti-medical extremism. This bias is generated by stories of midwifery births gone wrong that are passed along at conferences and on labor and delivery units and supported by the limited exposures that obstetricians have to midwife-supervised births, which unfortunately are predominantly excluded to those births which have not gone according to plan. If a midwife-supervised birth has gone well, the obstetrician need not ever lay a hand or eyes on the patient. It is only when problems arise which the midwife is unable to handle that the obstetrician is called in. This supports the obstetrician held view of the midwife as an inferior care provider, especially when the midwife seeking assistance has been managing the labor in a manner different from that which the obstetrician is accustomed.

For example, an obstetrician may be called in after a woman with a protracted labor has a prolonged and unsuccessful pushing stage. Perhaps she never received pitocin or an epidural, things this doctor would have standardly encouraged, and the patient has been permitted to push longer than this doctor would have typically allowed. The obstetrician inherits a swollen, exhausted patient who now needs a cesarean that is likely to be more complex, due to the engorged tissues and low station of the baby in the pelvis from the extensive pushing. She is more likely to have extensive bleeding and a uterine injury in this situation than she would have been if the surgery had been performed sooner. In the mind of the doctor, this patient would have been a lot better off if she had just gotten pitocin and an epidural. She would have reached fully dilated more rapidly and either discovered the baby was undeliverable sooner or been able to vaginally deliver because she would have been less tired. Her surgery would have been less complicated and her recovery easier because she would not have been exhausted from the long, tortuous labor. Perhaps in this situation the obstetrician is correct, as hindsight always is. However, what the obstetrician does not see are the other 10 deliveries this woman’s midwife has cared for in the exact same manner who went on to have healthy vaginal deliveries and never required the obstetrician’s services.