How Midwives Could Improve Maternal Health Outcomes in the U.S.

A new U.S. government report shows that 658 women in the United States died during pregnancy or shortly after in 2018—meaning that at least 658 families had to go through a devastating loss, and at least 658 children who will grow up without knowing the touch and love of their mothers.

Here’s the kicker: because maternal deaths are usually caused by conditions such as heart disease, infection and postpartum hemorrhage, more than half of those deaths were preventable. 

(Sandor Weisz / Creative Commons)

To even begin to reverse this national health care crisis, we must first recognize that many factors affect the safe passage of women through pregnancy, and babies through birth. Simply making sure a woman has access to a health care provider during pregnancy is not enough. The quality of the care she receives, the type of provider delivering that care and the setting in which she gives birth are among the crucial factors that help determine women’s pregnancies and birth outcomes. 

That’s why social factors greatly impact women during pregnancy and birth. The effects of inherent biases in the U.S. healthcare system and systematic racism on maternal outcomes cannot be overstated. When a black, college-educated woman is far more likely—243 percent more likely—to die from pregnancy or birth related causes than her white counterparts who never graduated from high school, we must acknowledge that the system that must serve all in fact serves only a selective few. Overall, black women in the pregnancy and early post-partum periods die at a rate three to four times higher than their non-Hispanic white and Hispanic counterparts 

How healthy a woman is going into pregnancy is also key. Women who enter pregnancy in a state of poor nutrition, whether they are underweight or obese, are at a greater risk for complications; women who enter pregnancy anemic also carry a burden of increased risk. Improving the physical, emotional and mental health of women overall, so that they enter pregnancy in an optimally healthy state, requires a commitment to universal, quality primary care. A healthy pregnancy doesn’t start with conception—it starts long before.

Fortunately, the Centers for Disease Control and Prevention are establishing better ways to monitor pregnancy outcomes. The CDC is also supporting state and regional perinatal groups to develop quality measures to change the landscape. In addition, we would do well to take one important lesson from other countries doing far better: the power of midwifery to improve maternal health outcomes.

In England, at least half of all babies are born into the hands of midwives, including both Princess Kate’s and Meghan Markle’s children. In Sweden and Finland, both countries at the top of their obstetric game, care during pregnancy is provided almost exclusively by midwives, with obstetricians involved in only high-risk pregnancies.

Even here in the U.S., a landmark five year study established that states wherein midwifery care is the most well-integrated—including Oregon, Washington and New Mexico—outcomes for both mothers and babies rank among the best. Alternately, those states with very low numbers of midwives and low systemic integration of them—including Alabama, Mississippi and Ohio— had significantly worse outcomes on key indicators of maternal and neonatal well-being. 

It is well past time for health systems, administrators, legislators, health care providers and the public to acknowledge that incorporation of midwives and the midwifery model and philosophy of care into our current broken system will make a positive difference for mothers and babies. 


Michelle Collins, Ph.D., CNM, RN-CEFM, FACNM, FAAN, is the Associate Dean of Academic Affairs and Professor of Women, Children and Family Nursing at the Rush University College of Nursing. She is a Public Voices Fellow with the OpEd Project.