The editorial board of the New York Times recently published a piece in praise of midwives, spurred by new guidelines out of the United Kingdom advising that low-risk pregnancies actually fare better out of hospital settings and under midwifery care. This editorial gives weight and visibility to an argument many in the birthing community have been making for some time: that midwives should be the standard of care for low-risk, healthy pregnancies, as well as key players in more complicated pregnancies. However, even as it championed midwives, the Times editorial board unwittingly slipped into language that suggests midwifery care is a second-tier option—language that reflects broader public attitudes throughout the United States.
The Times acknowledged that despite the difference in the British and U.S. health-care systems, “There is no good reason that midwives should not play a more important role in childbirth here.” Toward the end of the editorial, however, the board examined ways some organizations are trying to integrate midwives into their practices (emphasis ours):
Some medical centers are trying to have the best of both worlds by allowing midwives greater autonomy within the hospital. The Mayo Clinic, often a pacesetter, lets midwives handle low-risk pregnancies independently and hand off to doctors any cases that become complicated.
Words like “allowing” and “lets” imply a submissive relationship within the U.S. health-care system, in which permission may or may not be granted to midwives in order to practice what they have been trained, licensed, and certified to do. The above section also reinforces the idea that midwives drop care once a pregnancy gets complicated. In reality, however, midwives and doctors often work as a team for the benefit of a patient, rather than the midwife simply transferring care. While this was likely not intentional at all on the part of the New York Times, it’s clear that this way of thinking—that midwives are somehow seen as the lesser choice when it comes to birth providers—has become ingrained in how our society thinks and speaks about midwifery.
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Instead of using this value-laden language, the Times could have worded its assessment in a more egalitarian manner, such as: “At the Mayo Clinic, often a pacesetter, midwives practice independently and collaborate with physician when needed.”
Reframing the topic in this way also avoids playing into the idea of a “longstanding turf war between obstetricians and midwives,” as the Times put it elsewhere in their editorial. The situation is much more complicated than simply a “turf war” between two professions. While some individual providers might find themselves at odds, the false “turf war” narrative is more of a manufactured concept than it is representative of reality. Instead of fueling the false binary of doctors versus midwives, a shift in language in this way would uphold midwives and physicians as colleagues working together toward a shared goal of providing care that meets the needs of each individual patient.
Unfortunately, when it comes to midwives actually practicing, this type of language has set the stage, so to speak. In the United States, midwives—who are overwhelmingly female, which is a factor that cannot be overlooked in this discussion—are “allowed” to do their jobs, and only then with many constraints that often restrict them from practicing to the fullest extent of their licensure. Regulatory restrictions vary from state to state and affect the type of care midwives can provide, including where they can practice, what types of patients they are “allowed” to care for, and, oftentimes, how much they will be reimbursed for their services.
For example, although the Affordable Care Act stipulates that midwives should be reimbursed under Medicare 100 percent of the amount that physicians bill for identical service, the same can’t be said for Medicaid. The federal health-care program for low-income individuals’ reimbursement rate varies from state to state: A midwife may be reimbursed only 75 or 85 percent of the set fee for prenatal and delivery services, while a physician will receive 100 percent for the same work. This is vital to note, as Medicaid is often states’ largest single payer of Certified Nurse Midwife services, indicating the importance of midwives in marginalized communities.
Indeed, while some midwives are like those profiled in trend pieces in the New York Times, who care for white, upper-middle-class women, many others offer crucial services in underserved communities, taking on patients in low-income rural or urban areas where there may be provider and resource shortages.
And despite all of this, midwives remain unnecessarily regulated, both in language and in practice: set at odds with doctors rather than treated by legislators, the media, and the public as commensurate to them.
At the end of the day, it’s not about who provides the care that needs to change; rather, it’s our model of care that needs fixing. There is plenty of space and a great need for a range of providers—including physicians and midwives—when it comes to maternity care. Instead, however, we currently face a system that divides providers at the cost of the patient.
Health care in this country thrives in a for-profit world. And if you follow the money, you’ll see that this goes beyond midwives and doctors, into the insurance industry and corporate offices. Woven within this profit-centric system is the fact that the current approach in place driving maternity care in the United States is a biomedical model. This model—which focuses on pathology, physiology, and biochemistry of a disease, but does not bother to look at social, environmental, or psychological factors—procures the most revenue and is less patient-centric.
In these instances, it pays to follow the money trail and ask what type of care makes the most profit and for whom? Does the fact that providers are being paid more for interventions and the use of certain products influence their care? Are obstetric providers rewarded for the number of patients they see or for the slower-paced individualized care they can provide? Do hospitals receive more revenue for filling, or emptying, NICU beds? These are all questions we—both providers and patients—should be asking of our health care system.
As a whole, both the larger for-profit system and the biomedical model promote quantity over quality. Providers are rewarded for seeing more patients, because that brings in more revenue. This combination is at odds with the midwifery model of care—a model that has been shown to benefit both mother and infant. The American College of Nurse-Midwives carefully breaks down this model of care on its website, emphasizing the strong patient-provider relationship, patient agency, and individuality in care. It’s about long-term outcome improvements and quality over immediate revenue and quantity. Because of this, the midwifery model of care is disruptive to the for-profit/biomedical model. And disruption is exactly what is needed to fix this broken system.
When it comes to maternity care in the United States, the model of care needs to change to one where both physicians and midwives can flourish equally, as has been the case in the United Kingdom and other European countries. At present, we also need to be aware of how we discuss and frame the work of those providing care. Our for-profit system is set up to reward those billing more hours, patients, and procedures—due to the model of care they provide, that isn’t usually midwives. That has since translated into society viewing midwives as “less than” providers, despite evidence that they should be leading the way in all aspects of maternity care.
So, yes. Kudos to the New York Times for recognizing the immense benefit of midwifery care, but let’s go even further in our championing of the profession by respecting midwives in our action and our language. Hopefully the guidelines coming out of the UK will push this much-needed conversation into the mainstream and promote midwifery care in the United States. And, in the meantime, let’s do our best to talk about these providers of care in a way that is commensurate with their skill and evidence-based accomplishments.