In the U.S., maternal mortality continues to increase despite the availability of world-class healthcare resources. Research has shown that inequities are a critical component of the problem. Lack of access to care is a leading factor in maternal mortality, according to a March of Dimes 2022 report, which found that 2.2 million U.S. women of childbearing age live in maternity care deserts. Integrating care from nurse-midwives could better serve these areas.
According to the report, Nowhere To Go: Maternity Care Deserts Across the U.S., more than 146,000 babies were born in maternity care deserts, which the report defines as a county with:
- A lack of maternity care resources
- No hospitals or birth centers offering obstetric care
- No obstetric providers
As part of the solution to this problem, the report recommended expanding access to and improving the integration of the midwifery model of care. “This can help improve access to equitable and culturally informed maternity care in under-resourced areas, lower costs, reduce unnecessary medical interventions that contribute to risks of maternal mortality and morbidity,” and more, according to the study’s researchers.
Nearly 40% of U.S. counties without OB care
Researchers asserted that obstetricians (OBs), certified nurse-midwives (CNMs), and family physicians can all provide “quality maternal care.” Yet 39.8% of counties lack a single OB or CNM, and “capacity for midwives in rural areas has potentially been underutilized.”
Over half the counties (55.1%) did not have a CNM, a finding that revealed the degree to which care is lacking and provides a key insight into how to achieve incremental improvement. The study defined four levels of access to care, from maternity care deserts with virtually no care availability to low-access, medium-access, and full-access counties. While still having too few hospitals/birth centers, an increase to over just 60 OB providers per 10,000 births would change a county’s designation from maternity care desert to low-access. Providing avenues to educate and train more CNMs in these counties would save lives.
In a press release about the new report, Zsakeba Henderson, MD, March of Dimes Senior Vice President and Interim Chief Medical and Health Officer, said, “Our 2022 report confirms lack of access to care is one of the biggest barriers to safe, healthy pregnancies and is especially impacting rural areas and communities of color where families face economic strains in finding care.”
“We have struggled with a maternal mortality crisis for more than three decades,” observed Lora Sparkman, MHA, BSN, RN, in a blog discussing efforts to improve maternal outcomes. Sparkman, who is Relias Vice President and Partner, Clinical Solutions, Patient Safety and Quality, noted that despite advancements, “The U.S. maternal mortality rate remains stubbornly high, at 17.4 deaths per 100,000 live births.”
CNMs can bridge gaps in maternity care deserts
With maternity care deserts making up 36% of all U.S. counties, improving access to care and reducing the maternal mortality rate will require far-reaching efforts including changing policies, educating providers, addressing social determinants of health, providing technology support, and expanding access to midwifery care.
“Having CNMs in these known underserved areas would be a lifeline to these mothers,” Sparkman noted. “Not only would they provide evidence-based care, but they could direct and coordinate appropriate levels of care for mothers who are at a higher risk for birth-related complications.”
According to the 2022 March of Dimes report, previous research identified the following benefits to using a midwife during pregnancy and postpartum periods: “Midwifery care has been associated with an increased chance of having a low-intervention birth and lower cost of care due to significantly lower odds of medical intervention. Additionally, it has been associated with possible reduction of preterm birth and other adverse birth outcomes.”
Understanding cultural differences
International efforts show that midwives are often part of successful maternal care models. Nonprofit global health organization Jhpiego has learned that understanding cultural differences is critical for creating lasting change. Along with providing training and resources, Jhpiego helps midwives overcome the distrust of healthcare providers that often surfaces in marginalized populations. Successful practices include both personalized and community-based care approaches.
Ann Hyre, leader of Jhpiego’s Antenatal/Postnatal Research Collective (ARC), a Gates-funded initiative that seeks to help develop and implement new models of maternal health care to improve both patient and provider experiences, affirmed the applicability of these models in the U.S. “Midwives in the U.S. are faced with many of the same challenges as in other countries. Our work with midwives in other countries is really relevant here as well,” she observed.
Support from telehealth services
If bringing providers to low-resource communities is not feasible, telehealth could provide another bridge to services. In its report Improving Access to Maternal Health Care in Rural Communities, the Centers for Medicare and Medicaid Services reported that less than half of U.S. women living in rural areas are within a 30-minute drive to a hospital with obstetric services. Some states and health systems have successfully employed phone applications to provide perinatal services, such as the Text4baby initiative developed with input from the U.S. Department of Health and Human Services.
CNM role provides stability and job satisfaction
Across healthcare, retention of clinicians has been a challenge amid the pandemic, and CNM workforce issues are clearly a factor in access to care. A study in the Journal of Midwifery and Women’s Health done in fall 2020 found that full-time equivalent positions and number of full-time midwives were stable for 77% of the practices in the study, which covered all 50 states and the District of Columbia. Of the remaining practices, 15% lost and 8% gained full-time positions.
Notably, researchers found that ownership of the practice by a midwife was significantly associated with increased salaries, decreased loss of benefits, and lower incidence of furloughs. In a climate where prospective U.S. healthcare professionals seek meaningful, personalized work in which they have more autonomy and decision-making capabilities, independent practitioners in the form of CNMs could provide a good fit for areas that do not have hospitals or birthing centers, yet desperately need trained OB providers.
The March of Dimes report indicated that as of August 2021, there were only 13,403 CNMs/CMs in the U.S., even though 25 states provide full practice authority for CNMs. Certified professional midwives (CPMs), who provide care for “out of hospital” or community births, can legally practice in 35 states. Yet women living in rural areas currently use licensed midwives 12.5% less than women in urban areas. Rural Black women are especially less likely to deliver with a midwife, at 58.7% fewer choosing to do so, although rural Native American women are more likely do so at 11.5% more.
Bonding with patients and families
One nurse-midwife, Aiyana Davison, CNM, WHNP, RN, discussed the satisfaction that comes with being a CNM in a Nurse.com interview. She said that her duties “go far beyond the birthing experience” because she has been able to educate, bond, and grow with her patients and their families.
“I also witness great challenges when patients are dismissed or neglected in healthcare because of race, sexual preferences or identity, religious beliefs, or life morals and values. It’s crucial to let my patients and their families know they matter, and I will provide them with the best care I can offer.”
Advocating for the profession
The American College of Nurse-Midwives (ACNM) provides information on midwifery education programs and advocates for the profession’s impact on maternal and women’s health.
“The evidence supporting midwives and midwifery-led care is vast, and centering the voices and value of advanced practice midwives in public health and policy discussions is integral to improving our country’s alarming maternal mortality and morbidity outcomes,” ACNM Chief Executive Officer Katrina H. Holland said in a press release celebrating National Midwifery Week earlier this month.
Note: This article originally appeared on Nurse.com. This version includes additional information for hospitals and health systems.
How Mental Health and Social Determinants Are Driving Maternal Mortality
Mental health and social determinant factors are major contributors to maternal safety. Our white paper explores:
- Strategies for improving maternal mortality rates
- Social determinants of maternal mental health
- Racial disparities and how social determinants affect maternal mortality
- Findings on maternal mental health
- Five actions to combat the maternal mortality crisis