Why We Need More Midwives Now

| by Peggy O’Mara, Editor and Publisher

In 1973 I was living in southern New Mexico, pregnant with my first child and looking for a midwife. I didn’t know how to find one, so I went to a local obstetrician for prenatal care, all the while still hoping to find a midwife.

A woman my husband worked with had been a midwife in England, and two of my friends, who lived 200 miles away, were planning to become midwives. I called the New Mexico Department of Health, only to find that the state no longer licensed midwives.

My friends and I all wanted to have homebirths, but there were no midwives where we lived. We were awestruck by 
The Birth Book, the first book to publish graphic, step-by-step photos of birth for the layman, and were reassured by the National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC), an organization that held conferences on and published evidence about the safety of homebirth. Having a do-it-yourself mentality and trying to live lives of self-sufficiency, we naturally began to birth our babies ourselves.

Six months before our own first baby was born, my husband and I saw our friend Stephanie birth her son, Aram, at her home. We later helped to deliver the babies of three friends. I love birth, and was on my way to becoming a midwife, starting out, as had so many women before me, by helping a friend or neighbor. As Shafia Monroe, president of the International Center for Traditional Childbearing (ICTC), says, “Every woman 
is a potential midwife waiting to be born.”

As it turned out, while I loved helping the laboring mom, I was afraid of catching the baby. My husband always did that. Nor could I figure out how to be a midwife while being the mother of my own babies. In short, my life went in other directions.

Many of my contemporaries entered midwifery in a similar fashion and actually went on to become midwives. Elizabeth Gilmore, who cofounded the Northern New Mexico Birth Center and the Midwifery Education Accreditation Council (MEAC), and created the National College of Midwifery, began by helping her friends deliver their own babies on Martha’s Vineyard. Gilmore was instrumental in preserving and improving New Mexico’s licensure of midwives in the late 1970s, but when I interviewed her and her midwife partners in the early ’80s, they knew nothing about the legal status of midwifery in other states; they were too busy developing their own practices.

Supporting midwifery was part of the original mission of Mothering. I realized that, for midwifery to grow, we had to know what one another was doing, which legal strategies were working, which licensure processes were most effective. Parents and midwives alike needed to know the legal status of midwifery.

In 1981 we compiled our first edition of Midwifery and the Law, at first a special section in the magazine and then a small book. I remember how fellow editor Pacia Sallomi and I pored over the distinctions between the legal statuses of midwives in different states until we had distilled them down to a concise taxonomy. We published this book from 1981 to 1988, until the newly formed Midwives Alliance of North America (MANA) and other advocacy groups took over the task of identifying the legal status of midwives; they still use the taxonomy we created.

In 1982, sociologist Barbara Katz Rothman wrote her seminal work, In Labor: Women and Power in the Birthplace, in which she contrasts the midwifery and medical models of care. She put the yearning for midwifery care felt by so many of us within a context of human rights.

While that larger context of human rights may come as a surprise to those of us in the US, accustomed as we are to inferior care, it is not lost on Amnesty International. Their March 2010 report, Deadly Delivery: The Maternal Health Care Crisis in the USA, trains a spotlight on the US crisis in maternal health care. According to the report, a total of 1.7 million women a year—one-third of all pregnant women in the US—suffer from pregnancy-related complications. At greatest risk are minorities, Native Americans, immigrants, non-English speakers, and those living in poverty. “Good maternal care should not be considered a luxury available only to those who can access the best hospitals and the best doctors,” said Larry Cox, executive director of Amnesty International USA. “Women should not die in the richest country on earth from preventable complications and emergencies.”

According to the Centers for Disease Control and Prevention (CDC), US infant mortality failed to improve from 2000 to 2005. This plateau represents the first time since the 1950s that US infant mortality has seen no improvement. Even though the US spends more on health care than any other country in the world, we are ranked 33rd in the world in infant mortality. A baby born in Cuba, Slovenia, the Czech Republic, or South Korea has a greater chance of surviving the first year of life than a baby born in the US. In fact, a baby born in Singapore is twice as likely as a US baby to survive that first year.

The rate of infant mortality among non-Hispanic black women is 2.4 times what it is among non-Hispanic white women. One of the chief contributing factors to infant mortality is premature birth. In 2005, 36.5 percent of all infant deaths in the US were due to preterm-related causes; among the non-Hispanic black community, nearly half (46 percent) of infant deaths were related to prematurity.

Maternal mortality, too, is on the rise in the US, as it is elsewhere. In a joint statement, the World Health Organization (WHO), UNICEF, and other groups called maternal mortality the “largest health inequity in the world.” Ninety-nine percent of women who die in childbirth do so in the developing world, and 50 percent of those deaths occur in Africa. The WHO estimates that we need 350,000 more midwives to meet this global crisis. According to the International Confederation of Midwives, there are currently some 250,000 licensed midwives worldwide, and only 13,000 in sub-Saharan Africa.

We also need more midwives in the US, where each year approximately 10,000 midwives attend just 10 percent of births—about 430,000. If midwives attended 75 percent of US births, as they do in New Zealand—a country with a 12 percent lower rate of infant mortality than the US—we would need 75,000 more midwives.

The ICTC has a fast-track training program for midwives, but many more midwives are needed, especially from the African American community—evidence suggests that women of color birth best when attended by midwives of color. In fact, one of the criteria for a mother-friendly birth established by the Mother Friendly Childbirth Initiative is what is called culturally competent care: “that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.”

Eleanor Hinton-Hoytt, president of the Black Women’s Health Imperative, and other presenters recounted to attendees of the Seventh International Black Midwives and Healers Conference (held in Long Beach, California, on October 8–10, 2010) that it is commonplace for pregnant black women to experience racism in hospitals and doctors’ offices. These women report routine instances of white doctors who do not touch them or look them in the eye.

The ICTC conducted a pilot study in which 300 black women were asked about their care during pregnancy. Ninety percent of the women in the study reported being left alone during birth, and none was offered a doula. The ICTC intends to follow up the pilot study with a national survey.

While we have great affection for midwives, we may not fully realize how important their model of care is in the saving of actual lives. In 2007, the Journal of Perinatal Education (Vol. 16, Supplement 1, Winter 2007) published an extensive review of the research into maternity care done by the Coalition to Improve Maternity Services (CIMS) Expert Work Group.

The group found that the use of midwives is associated with:

  • •    longer prenatal visits

    •    more education and counseling during prenatal visits

    •    fewer hospital admissions

    •    less need for analgesia and/or epidural anesthesia

    •    increased use of alternative pain-relief methods

    •    more freedom of movement during labor

    •    more intake of food and drink during labor

    •    decreased instances of rupture of the membranes 

    •    fewer IVs

    •    less electronic fetal monitoring

    •    fewer inductions and augmentations of labor

    •    fewer injuries of the perineum

    •    fewer episiotomies

    •    fewer rectal tears

    •    more intact perinea

    •    fewer cesarean sections

    •    more vaginal births after cesarean (VBACs)

    •    fewer preterm or low-birth-weight babies

    •    more infants exclusively breastfeeding at two to four months after birth

The key to improving US maternity care is to provide midwifery care for all normal pregnancies. On July 21, 2010, Representative Lucille Roybal-Allard (D-CA) introduced House legislation for a sweeping reform of maternity care. The Maximizing Optimal Maternity Care Services for the 21st Century Act (HR 5807) authorizes a public-awareness campaign about evidence-based maternity practices, expands federal research into these practices, and authorizes data collection to pinpoint those most in need of maternity-care providers.

According to a press release from Roybal-Allard’s office regarding the MOMS bill, as it has become known, “Finally, the measure puts in place a concerted effort to create a more culturally diverse and interdisciplinary maternity care workforce. It establishes loan repayment programs for providers in maternity care shortage areas. It authorizes grant programs for maternity professional organizations to recruit and retain minority providers. It also calls for the development of core curricula across maternity professional disciplines to better ensure that providers are better trained and able to inform patients about all of their maternity care options.”

In addition to federal aid, it needs to be easier for women to become midwives. Currently, one of the most exciting models for midwifery training is at the community-college level. An exemplary model of midwifery education is Southwest Tech, in Fennimore, Wisconsin, where one can earn an associate degree in direct-entry midwifery that combines classroom instruction with apprenticeship. The program is accessible because it offers tuition assistance, affordable housing, and liaison with preceptors. And it can be replicated at other colleges.

If you’re interested in being a midwife, know that there is no type of professional more needed at this time. Here are some helpful resources for getting started:


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9 thoughts on “Why We Need More Midwives Now”

  1. I agree we need more midwives, but I also want to say that I WANT more midwives. Where I live (Canada), there isn’t really a crisis in maternal health, but midwives recently received funding from the government in the last few years. Great news… except that now so many people want midwives there aren’t enough to go around!

  2. In 1976 I gave birth to my first son at the University of Minnesota in a “birthing room”. Jeanette was my assisting midwife and I saw her for all my prenatal care and subsequently the natural birth of my son Jamisen. It was an experience that I’ll never forget. I was in control of the entire birth experience and called all the shots. My husband and midwife were there to assist me when I needed them. My second son was born with doctor assistance because I lived in Mankato. The experience was not comparable. My third son was born with a mid-wife and we traveled to Minneapolis from Mankato. There were no midwives available when my daughter was born 16 years ago. It seems to me we have traveled backwards.

  3. “In fact, a baby born in Singapore is twice as likely as a US baby to survive that first year.” No, I know the statistic and that is not it. Twice as many babies may die here per capita, but infant survival rates in the US is not half of those in Singapore (which would mean that a little more than half of all US babies did not survive their first year).

    Sorry, I just have a thing for the correct interpretation of statistics.

    I am also glad that my area of Chicago has competing midwife practices within walking distance of me (and another that only does home birth). One is even tempting located next to an amazing ice cream parlor.

  4. I agree with the fact that we need more midwives, but not that we aren’t in a maternal crisis in Canada. Many women are turning away from hospitals and doctor care in favor of midwifery care, mostly because of the imcompetence of the medical system to give women the beautiful empowering experience that women want birth to be. I have experienced this first hand, and have since become a birth doula to help other women to improve their birth experience. Until we bring midwifery and doula care into the mainstream, and change how doctors and hospitals approach childbirth, the maternity ward may become an antiquated institution.

  5. You are SO right! We need midwives, lots of midwives, all types of midwives, in the US and we need them sooner rather than later. Thanks so much for this great history and excellent advocacy, Peggy. We owe so much to our fore-mothers — both midwives like Betty Gilmore and pioneering consumers like you and your husband.

    These days we are fortunate in New Mexico in that 1/3 of all babies are being caught by midwives, and both CPMs and CNMs are licensed to provide midwifery services for women. One of the reasons midwifery has taken root and spread in NM is because midwifery has been licensed since the late 1970s and consumers in many (but not all) regions of the state are easily able to find out-of-hospital or hospital-based midwives to care for them during pregnancy and childbirth. Other states, however, are not so fortunate and are still working on bringing midwives in “out of the cold,” so they may practice legally under state regulation, with greater transparency for consumers, just as we enjoy in New Mexico. Midwives practice legally today in only 28 states, but many other states are now getting close to passing legislation, including Illinois (where the vote may take place THIS WEEK!), Massachusetts, Iowa, North Carolina, Indiana, Alabama, Mississippi, South Dakota, and Ohio are all poised to take a step or two forward this year. In each of these states, and many more, consumer advocates have joined with their midwives to lobby state legislatures for laws that will allow midwives to practice legally, to educate more midwives, and to be more accessible to consumers. As each state joins the “regulated legal practice” column, we see a greater number of out-of-hospital births, a growth in birth centers, a proliferation of new midwives and midwifery practices, and more students being educated in that state. The surest way to guarantee the growth of midwifery in the United States is to help midwives become licensed and regulated in ALL the states, not just the little over half of the states we have at present. The Big Push for Midwives Campaign encourages consumers to join their local Friends of Midwives or Safe Birth Options consumer groups to advocate for greater access to midwifery care through state licensure.

  6. Thank you for your comments, Susan, and for your hard work helping midwifery legislation. It’s exciting to see the effectiveness of the Big Push!

  7. Hi Peggy! What you have written is exactly right – we need more midwives. I have been developing a grant proposal under the auspices of the New Mexico Midwives Association called “The Partera Project.” It calls for the creation of direct-entry midwifery programs within our state college system, linked with the establishment of birth centers, to serve as both maternity care centers and clinical sites for midwifery students. As envisioned, such linked educational programs and birth centers would be located in communities in need of midwifery care. I would love to discuss “The Partera Project” in more depth with you and the Mothering staff – please feel free to contact me at ParteraProject@gmail.com. I will also be on the Healthy Woman radio program on 101.1FM in Santa Fe on Sat. Feb 5th at 2:30 pm, talking about midwifery. We taped the show today, and I quoted from this blog…Keep getting the word out!

  8. What we especially need is more Certified Nurse Midwife programs in this country! The reality is that more often than not, insurance covers hospital births more fully than home births and only CNMs can work in a hospital-based setting. I have chosen the CNM route because I can take a more diverse patient population than homebirth often allows (since medical is often terrible in compensating homebirth midwives). However I am WAITING to get into school!–as are several other aspiring midwives, some of whom are on their THIRD year of applying to CNM school. These are all passionate, exceptional, women well experienced in the birthing community…the reality is that there are not enough educational programs for those of us wanting to work in a hospital setting and improve care where the bulk of births take place. The sad truth 🙁 Hoping this will change…

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