Midwives and doulas are two distinct but complementary roles in maternal care that can improve clinical outcomes, patient experience, and access to care. Midwives provide clinical care during pregnancy, childbirth, and postpartum, while doulas provide non-clinical emotional, physical, and educational support.
For hospitals and health systems, integrating midwives and doulas is increasingly viewed as a strategy to address workforce shortages, improve maternal outcomes, and expand access — particularly in underserved and rural communities where more than half of counties lack hospital-based maternity services.
Understanding the roles of midwives and doulas
Midwives and doulas serve distinct but related functions and often work together within hospital and community-based care models.
A midwife provides medical care during pregnancy, birth, and the immediate postpartum period. Certified nurse-midwives (CNMs), who are typically registered nurses with graduate-level education and national certification, often practice in hospital settings and are integrated into clinical teams.
A doula provides the birthing person and family with emotional and physical support and education but does not perform clinical tasks. Doulas may assist with communication, care coordination, and patient advocacy, particularly for populations experiencing disparities in care.
Many birthing people choose to have both a midwife and a doula, and hospitals are increasingly exploring how these roles can complement physician-led care teams.
Midwife credentials and implications for hospital systems
Certified nurse-midwives (CNMs) complete accredited graduate-level education and pass a national certification exam. Other credentials include certified midwives (CMs), certified professional midwives (CPMs), and licensed midwives (LMs), with varying scopes of practice and regulatory requirements.
From a hospital perspective, these distinctions matter for:
- Credentialing and privileging
- Scope of practice and supervision requirements
- Integration into obstetric care teams
In the U.S., approximately 12% of births are attended by midwives, and this number has been increasing, signaling a growing workforce opportunity for health systems.
Why midwives and doulas matter to hospitals and health systems
Patient preference and healthcare system pressures are driving increased interest in midwives and doulas, but the implications go beyond patient choice.
Health systems are facing:
- OB workforce shortages
- Rising maternal morbidity
- Pressure to improve outcomes and reduce costs under value-based care
Evidence shows that integrating midwives and doulas can help address these challenges:
- Midwifery care is associated with lower rates of cesarean and preterm birth and improved newborn outcomes.
- Doula support is associated with a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth, along with increased postpartum follow-up.
For hospital leaders, these outcomes translate directly into:
- Improved quality metrics
- Reduced complications and costs
- Better patient experience scores
Birth settings, outcomes, and what they mean for hospitals
Free-standing birth centers, where midwives typically provide care, have grown in recent years. While they represent a small percentage of total U.S. births, their outcomes have drawn attention from policymakers and healthcare leaders.
Research has shown that midwife-led models are associated with:
- Fewer cesarean births
- Fewer preterm births
- Higher rates of breastfeeding
However, many of these outcomes are influenced by patient risk selection. For hospitals, the key opportunity is not competition with birth centers, but adapting successful elements of midwifery care within hospital-based models.
This includes:
- Expanding midwife-led care teams
- Incorporating low-intervention protocols where appropriate
- Aligning care delivery with patient-centered models
Integrating midwives and doulas into hospital care models
Two primary models of maternal care are often discussed: the midwifery model and the medical model. In practice, most hospitals operate along a spectrum that blends both approaches.
For health systems, the focus is shifting toward integrated care models, including:
- Midwife-led units within hospitals
- Collaborative OB-GYN and midwife teams
- Doula-inclusive labor and delivery policies
Hospitals are increasingly encouraged to adopt doula-friendly policies, provide staff training, and align doula services with evidence-based care practices.
These models can:
- Improve patient trust and communication
- Enhance care coordination
- Reduce unnecessary interventions
Operational and financial considerations for implementation
Despite growing interest, hospitals must navigate several operational challenges when integrating midwives and doulas:
- Reimbursement and coverage: Medicaid coverage for doula services is expanding, but reimbursement rates and policies vary by state.
- Workforce supply: Access to midwives and doulas may be limited by training capacity and geographic distribution
- Scope of practice regulations: State-level variation can affect how midwives practice within hospital systems
Hospitals evaluating these roles should consider key performance indicators such as:
- Cesarean section rates
- Preterm birth rates
- Patient satisfaction scores
- Postpartum follow-up rates
Midwives and doulas as a strategy to expand access to care
Midwives and doulas can play a critical role in addressing gaps in access, especially in rural and underserved areas.
In the U.S., more than half of rural counties lack hospital-based maternity care services, contributing to disparities in maternal outcomes.
Because midwives and doulas can work across settings, including hospitals, birth centers, and community environments, they offer a flexible and scalable approach to expanding care.
Additionally:
- Doulas can improve care access and patient navigation for underserved populations
- Midwives can extend the clinical workforce and increase provider availability
These roles are increasingly being recognized in federal and state strategies to improve maternal health outcomes and reduce disparities.
Key takeaways for healthcare leaders
- Midwives and doulas are complementary roles that can enhance hospital-based maternal care
- Evidence shows improved outcomes, including reduced cesarean and preterm birth rates
- Integration supports workforce strategy, helping address provider shortages
- Adoption requires operational planning, including credentialing, reimbursement, and care model design
- These roles can expand access to care, particularly in underserved communities
Promoting Vaginal Birth: A Guide To Understand and Lower the Cesarean Birth Rate
Currently in the U.S., we are faced with a high rate of cesarean births, which brings associated short- and long-term risks to both birthing people and babies when these procedures are not medically necessary. Hospitals, providers, and nurses need insights into the factors driving these high rates — and access to effective strategies to promote vaginal birth and maintain cesarean birth rates at targeted levels.
Download the research brief →
