Midwifery linked to better birth outcomes in state-by-state report cards

The first-of-its-kind study found a strong connection between the role of midwives in the health care system -- what the researchers call "midwifery integration" -- and birth outcomes. States with high midwifery integration, like Washington and Oregon, generally had better results, while states with the least integration, primarily in the Midwest and South, tended to do worse. The findings were published today in the journal PLOS ONE.

"Our findings suggest that in states where families have greater access to midwifery care that is well integrated into the maternity system, mothers and babies tend to experience improved outcomes. The converse was also demonstrated; where integration of midwives is poorer, so are outcomes," said Melissa Cheyney, a licensed midwife, medical anthropologist and associate professor in Oregon State University's College of Liberal Arts and one of the study's co-authors.

As with most population health studies, the statistical association between the role of midwives and birth outcomes doesn't prove a cause-and-effect relationship. Other factors, especially race, loom larger, with African-Americans experiencing a disproportionate share of negative outcomes. However, almost 12 percent of the variation in neonatal death across the U.S. is attributable solely to how much of a part midwives play in each state's health care system.

"In communities in the U.S. that are underserved -- where the health system is often stretched thin -- this study suggests that expanding access to midwifery is a critical strategy for improving maternal and neonatal health outcomes," said Saraswathi Vedam, an associate professor in the Department of Family Practice at the University of British Columbia, who led the team of U.S. epidemiology and health policy researchers responsible for the study.

About 10 percent of U.S. births involve midwives, far behind other industrialized countries, where midwives participate in half or more of all deliveries. Each state has its own laws and regulations on midwives' credentialing, their ability to provide services at a client's home or at birth centers, their authority to prescribe medication and the degree to which they are reimbursed by Medicaid.

"A large body of cross-cultural research has actually demonstrated similar relationships between midwifery care, systems integration and improved maternity care outcomes," Cheyney said. "This study is important because it suggests that the same relationships hold true in the United States. There are significant policy implications stemming from this work."

The research team created a midwifery integration score based on 50 criteria covering those and other factors that determine midwives' availability, scope of practice and acceptance by other health care providers in each state.

Washington had the highest integration score, 61 out of a possible 100, followed by New Mexico at 59 and Oregon at 58. North Carolina had the lowest score, 17. The complete list, with links to each state's report card, is available online at http://www.birthplacelab.org/how-does-your-state-rank/.

An interactive map created by the researchers reveals two clusters of higher midwifery integration -- one swath stretching from the Pacific Northwest to the Southwest, and a cluster of Northeastern states.

Vermont, Maine, Alaska and Oregon had the highest density of midwives, as measured by the number of midwives per 1,000 births. The lowest midwifery integration was in the Midwest and Deep South.

The study used higher rates of vaginal birth and breastfeeding as positive maternity care outcomes. Higher rates of caesarean birth, premature births, low birth weight and newborn deaths were indicators of poor outcomes.

The Deep South, which not only had lower integration scores, but also higher rates of African American births, had the worst rates of premature birth, low birth weight and newborn mortality. The West Coast states of California, Oregon and Washington consistently scored well on those measures.