The United States is one of the most dangerous places to give birth in the industrialized world, as the maternal mortality rate has increased over the last several decades. With that as context, it is important to understand the connection between access to care and overall outcomes. There are significant racial disparities in maternal health outcomes. Overall, Black women die from pregnancy or childbirth at a rate two to three times that of white women. These disparities also exist for infant health outcomes. We know that by improving access to care, including to a spectrum of providers such as midwives and doulas, disparities are reduced and better maternal health outcomes are achieved.

In 2020, the March of Dimes found that 1,095 counties in the United States lack maternity care.

Despite what appears to be a robust health care system, in 2020, the March of Dimes found that 1,095 counties in the United States lack maternity care (no hospital offering obstetric care, no birth center and no obstetric provider).^[1] This includes 14 counties in Ohio.^[2] There are more than 2.2 million women of childbearing age living in these counties and in 2017, nearly 150,000 babies were born to women living in these counties. These maternity care deserts span urban and rural areas of the country. A report from the federal Centers for Medicare and Medicaid Services (CMS) found that counties with greater proportions of Black and Hispanic populations and those with an overall lower median income were more likely to lack a hospital with obstetric services.^[3]

While there are myriad factors contributing to lack of maternity care access and just as many potential ways to make improvements, one recommendation in particular is to increase access to midwifery services. We have explored the role of midwives, the history of midwives in this country and how a devaluation of their role as birth professionals, based in racist and sexist stereotypes, lead to their inconsistent integration into the current health care system. Midwives seek to normalize pregnancy and childbirth as routine parts of a woman’s life course and care. Midwives also play an important role in deinstitutionalizing childbirth and bringing community-based support to hospital-based deliveries, which is key to reducing disparities resulting from health care institutions that often provide care influenced by bias and racism. We have also explored^[4] the different classifications of midwives and how there is a wide range in the level of integration into the health care system dependent on the state in which you reside. State policies play a significant role in overall access to midwives and the Midwifery Integration Scoring System (MISS) shows that Ohio ranks on the low end of states for integrating midwifery services.

Low-risk births attended by midwives in rural areas were shown to have just as good or better outcomes and higher satisfaction than those with physicians.

Policy changes across the country, and in Ohio, are needed to support increased access to a range of midwifery services. Low-risk births attended by midwives in rural areas were shown to have just as good or better outcomes and higher satisfaction than those with physicians.^[5] This is key in filling the gaps identified across urban and rural areas in overall maternity care. Certified midwives, who are often more closely connected to the communities they serve, can locate their services more easily, compared to hospitals and physician practices, in maternity care deserts. CMS identifies a “multidisciplinary workforce” as one strategy to improve access to maternity services in rural areas.^[6] Policymakers in Ohio should closely examine the MISS, as these are seen as key steps to increasing access to midwifery services. One scoring factor in the MISS is whether there is certification in that state for certified midwives (CM). Ohio does not have a formal certification for CMs. And of course, certification plays a role in whether CMs can be reimbursed through Medicaid and other insurance. In the last few years, Alabama, a state with the second to lowest MISS score as well as the fewest maternity care providers per capita and the highest infant mortality rate, passed a law for certifications of lay midwives.^[7] Steps like these can help to build trust in midwifery services and position them as extenders of maternity care where there is limited availability.

[1] https://www.marchofdimes.org/materials/2020-Maternity-Care-Report-eng.pdf

[2] Carroll, Champaign, Fayette, Hardin, Jackson, Lawrence, Meigs, Monroe, Morrow, Noble, Paulding, Perry, Putnam, and Vinton

[3] https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf

[4] https://www.communitysolutions.com/midwives-regulated-ohio/

[5] http://ruralhealthquarterly.com/home/2018/07/09/might-midwives-help-fill-rural-maternity-care-gaps/

[6] https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf

[7] http://ruralhealthquarterly.com/home/2018/07/09/might-midwives-help-fill-rural-maternity-care-gaps/