Almost 6 million birthing people live in a US county classified as a maternity care desert, an area with limited or no access to an obstetric provider like certified nurse midwives/certified midwives (CNMs/CMs) or obstetrician/gynecologists (OBs). In 2020 one in 12 birthing people live in a maternity care desert and there are significant disparities in access. Approximately 1 in 4 of Native American babies (26.7%) and 1 in 6 Black babies (16.3%) were born in maternity care deserts. Alarmingly, approximately one-third (36%) of US counties are maternity care deserts and this number is growing yearly. These rapid changes are occurring alongside a critical moment in US maternal health in which the country reckons with a rising maternal mortality rate, deep racial disparities in a wide range of maternal health outcomes through the continuum from pregnancy to postpartum, and a growing awareness of the role of disrespect and mistreatment in routine maternity health care (Vedam et al., 2019).
Access to maternity care is dwindling and birthing people are dying. We must invest resources in a multi-pronged strategy that includes many potential solutions. Scaling up midwifery care is one promising strategy to bridge the gap in care for birthing people who live in maternity care deserts.
Midwives are health professionals trained to provide care during pregnancy, childbirth, and the postpartum period. Some midwives, including certified nurse midwives and certified midwives (CNMs/CMs) and others may also provide sexual and reproductive health; gynecologic health; and family planning services, including fertility and preconception care. Midwives provide evidence-based care and are less likely to have a preterm birth and more likely to have a spontaneous vaginal birth with the midwifery model of care (Sandall et al., 2016).
However, historical campaigns against midwifery that targeted Black and immigrant midwives in the 20th century (Goode, 2015) along with prohibitive local, hospital, state, and federal policies have prevented midwives from fully integrating into the healthcare system. This lack of integration negatively impacts outcomes, access, and quality of care (Vedam et al., 2018). Midwives provide care within a relationship-centered model that prioritizes respect, and autonomy, two crucial components of quality maternity care.
We need more research to better understand how integrating midwives more fully into the healthcare system can provide a solution to maternity care deserts. We need to identify factors that influence positive collaboration between midwives, physicians, and nurses. We also need to examine the potential impact of community-based models of midwifery that can address maternity care deserts and reduce racial disparities in maternal health outcomes.
As nurses and midwives, we need to advocate for policy changes that help to increase the number of midwives. Some recent policy efforts indicate that policymakers are heeding the call to invest in midwifery. HRSA recently made available $8 million dollars in funding to support accredited nurse midwifery programs to train nurse midwives through trainee scholarships, stipends, curriculum enhancement, and community-based training in the U.S. through the Maternity Care Nursing Workforce Expansion (MatCare) Program.
We also need to advocate for the passage of the Black Maternal Health Momnibus Act, a legislative package of 13 bills that address structural drivers, like racism, that fuel racial inequities in perinatal health. Each bill was introduced by a member of the House Black Maternal Health Caucus, co-founded by Johns Hopkins School of Nursing graduate Representative Lauren Underwood (D-IL), Representative Alma Adams (D-NC), and Representative Senator Cory Booker (D-NJ). The Perinatal Workforce Act, legislation included in the Momnibus, would investigate barriers that prevent racially and ethnically diverse individuals from entering maternity care professions and establish funding to increase the number of diverse midwives and other maternity care providers. These are critical actions that can help us to bring more maternity care providers to areas with minimal or low access to maternity care.
As we understand more about the deficits in the current maternity care system we must advocate for promising solutions, like midwifery care. The time to act is now.
References
Goode, K. L. (2015). Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism. [ProQuest, Ann Arbor MI]. In Dissertation Abstracts International, A: The Humanities and Social Sciences (Vol. 76, Issue 03). http://www.proquest.com/docview/1718065355/C552D5A86BAE4A53PQ/4
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife‐led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4. https://doi.org/10.1002/14651858.CD004667.pub5
Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, R., Cheyney, M., Fisher, T., Butt, E., Yang, Y. T., & Kennedy, H. P. (2018). Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLOS ONE, 13(2), e0192523. https://doi.org/10.1371/journal.pone.0192523
Vedam, S., Stoll, K., Taiwo, T. K., Rubashkin, N., Cheyney, M., Strauss, N., McLemore, M., Cadena, M., Nethery, E., Rushton, E., Schummers, L., Declercq, E., & the GVtM-US Steering Council. (2019). The Giving Voice to Mothers study: Inequity and mistreatment during pregnancy and childbirth in the United States. Reproductive Health, 16(1), 77. https://doi.org/10.1186/s12978-019-0729-2
About the Author: Dr. Noelene K. Jeffers
Dr. Noelene K. Jeffers, PhD, MSN, BS, RN, is an Assistant Professor at the Johns Hopkins School of Nursing. has over 10 years of experience as a nurse-midwife serving families in federally qualified health centers, hospitals, and free-standing birth centers in Washington, DC. Dr. Jeffers utilizes a reproductive justice lens to examine the structural and social determinants of Black maternal and perinatal health and currently leads studies to examine the impact of midwives and birth center care on perinatal health, racism, and discrimination in midwifery education programs, and the integration of doulas into state perinatal health systems.
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