You May Want To Give Birth With A Midwife

The case for evidence-based birth and why midwifery matters

Back in my short-lived tweeting days, one particular tweet got a lot of attention. To this day, I’m not sure what was so special about this tweet in comparison to my other hot takes, but somehow the algorithm decided that 5 million people were going to be exposed to it. Weird.

The responses were varied, with people in midwife-friendly countries responding “Well, yeah, duh—of course midwives are better at low-risk birth” and angry American obstetricians warning of the dangers of midwifery. Lots of people shared their positive and negative birth stories with various delivery attendants. To be honest, I could barely keep up and I’m not sure I even read all the responses.

But my biggest takeaway was that many people—mostly moms, but also their partners and family members—are deeply dissatisfied with how they were treated during childbirth. This didn’t surprise me at all.

Before I became a midwife, I worked as a labor and delivery nurse, and I saw a lot of things that traumatized me—scenes I replayed while lying awake after night shifts, too angry to sleep. I was angry at the physicians I worked with for the way they treated women, but also angry with myself for not knowing how to intervene. In my defense, I was new to the birth arena, but because I was in midwifery school at the time and also attending births with midwife preceptors, I knew there was a better way possible. I saw that midwives and physicians approach birth in profoundly different ways.

Quick disclaimer: I am at a different point in my career now where I work with wonderful OB/GYNs. While our philosophies still differ in certain ways, I don’t want to give the impression that all physicians are alike, or that you can’t have a nice birth with one. Personally, I find their skills invaluable for helping moms and babies get the best outcome possible. I’ve also noticed that the new OB residents coming in are very different than the physicians of years past—more committed to evidence-based practice and more respectful of midwives and other advanced practice nurses. In an ideal system, respectful collaboration between midwives and doctors results in the best outcomes.

But here are some things I saw as a labor and delivery nurse in this dominant physician model:

• performing cervical checks, amniotomies (breaking the bag of water) without clear consent

• yelling at women during childbirth, especially during the pushing phase (this is what I was addressing in the tweet!)

• disregarding birth plans

• routine cutting of episiotomy (known to be a non-evidence based practice for ~30 years)

• C-sections done for physician convenience rather than legitimate medical reasons

• Restricting movement, food and fluids during labor

A CDC survey shows that one in five women reports mistreatment during maternity care—a number that rises to one in three for women of color. Nearly half say they held back from asking questions or sharing concerns during their maternity care.

After 20 years working in maternal health, I feel strongly that integration of midwifery into the U.S. healthcare system is one of the most powerful steps we could take to meaningfully improve both the experiences and outcomes of moms and babies.

But currently, only 12% of births in the U.S. are attended by midwives. So this post mainly focuses on convincing the American public why they or their loved ones may want to give birth with a midwife—or at least in a setting that includes midwives—an approach that, as I’ll show later, also leads to better overall outcomes.

Part 1: What is a midwife?

First, I want to be clear on what I’m talking about. The word “midwife” is thrown around quite a bit, such that Court TV’s coverage of a trial wherein an infant died after a home breech vaginal birth after cesarean (VBAC) was deemed the “Midwife Delivery Death Trial” even though the person attending the birth did not have any recognized credential as a midwife.

For the purpose of this post, a midwife has one of these credentials: certified professional midwife (CPM), licensed midwife (LM), certified midwife (CM) or certified nurse-midwife (CNM). It would take a while to explain the differences between these midwives, and it varies which states license which midwives. Suffice it to say, most (~90%) midwife-attended births in the U.S. are attended by CNMs, who are licensed in all 50 states, and who mostly attend hospital births. Most home births are attended by CPMs, who are licensed and credentialed in 37 states, last I looked. This document is extremely helpful if you want to understand more about the midwifery workforce.

As you can see, CNMs attend about 90% of midwife-attended births in the U.S., and 93.7% of those occur in hospitals

Part 2: In the world’s best maternity care systems, midwives are the norm

Why do I feel so strongly that midwifery would improve birth in the United States? First, because midwife-led care is the dominant model in the world’s best maternity care systems, as defined by those who have the lowest neonatal and maternal mortality rates. In most of Western Europe, the default option is to have a midwife care for you during pregnancy and childbirth, and physicians are consulted and used when a birth goes into high-risk territory. Here’s a table I compiled comparing U.S. outcomes to a few other countries with a dominant midwifery model of care:

*WHO/World Bank 2022-2023 **National reports/midwifery associations

And here is a table looking at the midwife and OB/GYN workforce in different countries. As you can see, midwives vastly outnumber OB/GYNs in most of Western Europe.

Part 3: Midwifery is more integrated in the U.S. states with the best outcomes

But a lot of people reject this data, saying things like “Well, those countries are different. They’re more homogenous, and they have universal health care. So we can’t assume we’ll get the same outcomes by doing the same things.”

But, why do U.S. states with greater midwifery integration also have better outcomes? In Vedam, 2018 the authors created a midwifery integration score for each state, considering factors such as scope of practice, midwife autonomy, prescriptive authority, and access across birth settings (home, birth center, hospital). They found that states with broader scope of practice, higher midwife autonomy, and more supportive laws consistently had better maternal and neonatal outcomes—even after controlling for race. Simply put, stronger midwifery integration was linked to better outcomes!

There were higher rates of:

1. Spontaneous vaginal birth

2. Vaginal birth after cesarean (VBAC)

3. Breastfeeding

And lower rates of:

1. Cesarean

2. Preterm birth

3. Low birth weight infants

4. Neonatal death

They also found that states with better midwifery integration correlated to higher density of midwives and, therefore, greater access to care across birth settings (aka fewer maternity care deserts).

A map showing which states have the most midwifery integration (highest quartile) versus the least

Part 4: Even people who are not good candidates for midwifery care benefit from midwifery integration

You may be thinking, “Well, ok, but a midwife is not the right choice for everyone.” This is true! Some people are too high risk to give birth with a midwife—maybe they have chronic conditions like hypertension or diabetes, or are pregnant with twins, have a placenta previa or some other serious complication. But even those moms benefit from giving birth in settings where midwives are integrated.

Two studies compared women who experienced care in interprofessional settings—where both midwives and physicians attend births—with those who received care in physician-only settings. Carlson, 2019 found a 36% lower cesarean rate and 31% higher VBAC rate while Neal, 2018 found a 12% reduction in cesarean births for the same group. Neither study showed a difference in neonatal outcomes.

In a California study comparing 106 hospitals with midwives to 156 hospitals without midwives, Chaiken, 2023 found about 20% lower odds of both operative vaginal birth (vacuum or forceps) and cesarean for the hospitals where midwives are integrated. They stated in their conclusion in this major U.S. obstetric journal, AJOG:

These results indicate that the presence of midwives in hospitals may impact practice of all obstetric providers at the institution. Further work should investigate how inclusion of midwife birth attendants at a hospital changes institutional culture, patient population, and related outcomes.

Part 5: More women want a midwife than have access to a midwife

Unfortunately, the U.S. is a country with a strong history of marginalizing midwifery. Basically, a campaign by the American Medical Association in the early 1900’s worked hard to discredit midwifery, removing training programs and passing restrictive licensing laws. These two actions effectively made midwifery illegal, basically eradicating it in the U.S. by the 1940’s. The end result is that current day American midwives have a lot to bounce back from—midwifery is just not well integrated into our healthcare system, and a lot of forces are trying to keep it that way.

But, at least currently, women not wanting a midwife just isn’t the problem. In fact, about half of women said they would be interested in having a midwife for their birth, but far fewer actually had one.

Part 6. Women who have a midwife for prenatal care and/or birth report greater satisfaction and have better outcomes

Women who experience midwifery care report greater satisfaction: better communication, being less likely to hold back questions, and less likely to feel rushed. In labor and delivery settings, they say they had greater decision-making autonomy and were offered more nonpharmacologic pain relief measures.

When it comes to avoiding undesired outcomes, low-risk first time moms were shown by Souter, 2019 to have a 30% lower chance of cesarean if cared for by a midwife, while moms who had given birth previously were 40% less likely to experience a cesarean. Operative birth (vacuum or forceps) was also about 30% less common.

In one of my favorite studies done by the Center for Medicare/Medicaid (CMS), moms who were deemed high risk for preterm labor were offered enhanced prenatal-care models, including midwifery-led birth center care. The moms who had this intervention had significantly lower rates of preterm birth, low birth weight and cesarean section, which points to the value of midwifery care in settings that embed continuity and psychosocial support typically given by midwives.

In contrast, the only U.S.-approved drug specifically for preventing recurrent spontaneous preterm birth, Makena (17-α hydroxyprogesterone caproate), was withdrawn by the FDA in April 2023 after new data failed to confirm its effectiveness. The U.S. healthcare system spent millions on this drug despite its high cost and questionable efficacy.

Sadly, though midwifery continuity of care is one of the few interventions shown to make a difference in preventing preterm birth, the U.S. healthcare system continues to look for a “magic bullet.” We want to treat preterm birth like a biomedical problem rather than the social/structural problem that it is. Integrating midwifery into our healthcare system may be the most under-leveraged strategy to reduce preterm birth in the U.S.

Conclusion: You may want to give birth with a midwife

Last year, I was sitting in a lawn chair at the park waiting for my son’s soccer game to begin, and I overheard two pregnant moms talking about their prenatal care, so naturally I had to eavesdrop. The conversation went something like this:

Mom 1: Who’s your OB?

Mom 2: Oh, I don’t have an OB. I’m using a midwife at XYZ Medical Center.

Mom 1: Nice. I’ve heard good things about that midwifery group. Are you in their water birth study?

Mom 2: Hell, no. I’m getting an epidural.

Mom 1: Ha ha, yeah, I’d get an epidural now if I could.

I kinda had to laugh, and I found this conversation uplifting. Why? Because it showed me that moms are starting to understand the different options for care you can consider—while still using a midwife.

Recently, I trained in water birth and started attending them at the hospital where I work. It’s so exciting to see more options being offered in the hospital. But I’ll be honest—these innovations in care, this expansion of choices—it usually has midwives behind it. In fact, it was one of my former midwifery students who pushed for water birth to be available at our hospital.

Similarly, it was the midwives in our group who, 18 years ago, pushed my hospital to adopt policies ensuring immediate skin-to-skin contact, delayed cord clamping, early breastfeeding, and that mothers and babies remain together during the first hour of life.

Before this change, it was routine for many doctors to cut the cord immediately and separate the baby from mom. Some physicians resisted the new policy, saying things like, “But now I have to wait an hour to get the birth weight for my birth note!” In the end, we midwives, along with nurse colleagues, insisted that a mom and baby’s experience matters more than paperwork or convenience. Today, almost no one questions this evidence-based policy. In fact, a recent Cochrane Review found the evidence for immediate skin-to-skin contact so compelling that the authors concluded it would no longer be ethical to withhold it from mothers and babies.

In short—midwives make a difference! Whether it’s obvious or not, our quiet influence is pushing birth narratives toward a more humane, evidence-based, and family-centered experience.

Photo cred Laura Brink of Rewild Her, Huffington Post Birth Photos

I hope you found this post enlightening. If you have any questions or thoughts, please leave them in the comments—I’m always happy to engage respectfully with differing opinions. And please subscribe to A Moderate Midwife for more pregnancy and birth-related takes!