GateHouse Media’s recent coverage of community birth raises some important considerations for midwifery in the United States. For example, this piece provides an important opportunity for families who have experienced loss to tell their stories. No family should feel judged for their birth choices or their decision to share their story, regardless of birth outcome. It also appropriately makes the point that, as in all health care fields, providers found incompetent in one state should not be allowed to cross state lines and continue to practice.
However, for us, this story also highlights the importance of examining the US maternity care system as a whole, including the role of care provided in US hospitals, which accounts for just under 99% of all births—a position not emphasized by the authors of the original piece. The recent award winning ProPublica series Lost Mothers, for example, takes an in-depth look at preventable deaths within the US maternal health care system. It finds that the United States has the highest maternal mortality rate of all high resource countries and is the only similarly resourced country with a rising maternal death rate. Black and Indigenous families, in particular, bear the burden of institutionalized racism and our failing maternity care system, suffering 2-3 times more maternal deaths than their white counterparts.
The US also has dangerously high cesarean section rates, which are associated with excess harms and long-term negative health implications for mothers, their babies, and for subsequent birth outcomes. Research published in the British Journal of Obstetrics and Gynaecology found that when cesarean is the mode of birth, it adds one more unexplained stillbirth per 1000 in the next pregnancy as compared to vaginal birth.
In addition, the Gatehouse reporters missed, over the course of their investigation, the significant efforts already underway in the US to advance high-quality collaborative care across all sites of birth. When we look to other high resource countries, we find that optimal outcomes in childbirth are achieved when collaborative care—in which all birth settings and providers are integrated into the healthcare system—is the norm, instead of the exception. This lack of integration in many areas of the United States reduces the ability to have regular, transparent, and informative quality reviews that lead to optimal outcomes. It also keeps intrapartum transfers (transfers during labor) from the community setting to the hospital from being as smooth and seamless as possible. Research backs up the need for increased integration; one important study found that increased access to and greater integration of midwives in the United States is associated with improved outcomes for families across birth settings, even when taking into account the impact of race.
Going forward, we anticipate that families will continue to choose to give birth in community settings. These choices are made for a variety of reasons, including a desire to receive care that uses interventions like cesarean section only when necessary; previous experiences of mistreatment; and the positive health benefits that come from comprehensive, individualized care. Articles that create an environment of hostility by sharply criticizing women’s choices and stigmatizing one kind of provider or birth location over others do nothing to ensure safety for childbearing families. Perhaps the most concerning result of such polarization is limited access to care, which disproportionately affects people in already marginalized communities. Safe birth advocates and researchers are working collectively to cast light on the issues that impact clinical, cultural, and emotional safety during birth in all settings, and we welcome journalists to join in these efforts.
Sadly, this piece provided families and other readers with a narrow, one-sided and incomplete look at the harms families currently face in the US maternal health care system at large. Moreover, this article further fractures the landscape of US childbirth in a time when collaboration and innovations are needed more than ever to address the US maternal health care crisis and to ensure optimal health for all.
Division of Research Coordinating Council, Midwives Alliance of North America
American Association of Birth Centers
American College of Nurse Midwives
Association of Midwifery Educators
Birth Place Lab
Citizens for Midwifery
International Confederation of Midwives
Midwifery Education Accreditation Council
National Association to Advance Black Birth
National Association of Certified Professional Midwives
National Black Midwives Alliance
North American Registry of Midwives
Queer and Transgender Midwives Association