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Kira Johnson, a Black mother-to-be, tragically lost her life hours after a routine cesarean section (C-section) in 2016, a result of internal bleeding that was left untreated for too long. Kira was young and healthy — and her death was preventable.
The United States is facing a maternal health care crisis. The country has one of the highest maternal mortality rates in the developed world, a number that has been on the rise for the past two decades. The risk of death is even higher for Black and Native American including Alaska Native women. While some of these disparities can be linked to socioeconomic status, they also affect highly educated women of color like Kira.
Central to combatting this issue is building a maternal care workforce that includes roles that can provide support and advocacy to women during pregnancy, labor, and delivery, as well as post-partum. According to a report from the Commonwealth Fund, while there is a shortage of maternity care providers relative to births, obstetrician-gynecologists (OBGYN) are overrepresented compared to other providers. In many other countries, midwives outnumber OBGYNs and play a significant role in the health system and maternal care. Bringing greater attention to the range of caregivers and making more resources available is vital to improving maternal health outcomes — including reducing deaths, C-sections, and other pregnancy and birth-related challenges.
A guide to maternal health caregivers
While both midwives and OBGYNs are medically trained to care for expectant parents and deliver babies, their approaches to care and skillsets are unique. Doulas are also part of the maternal health care workforce; however, their role is to support the needs of the birthing person rather than perform the delivery or provide medical advice or intervention. Here are the key roles of each caregiver:
OBGYNs are medical doctors that specialize in women’s reproductive health. They can perform surgery, most commonly C-sections. They’re trained to support high-risk pregnancies, which can range from an individual at an advanced age, to someone who is dealing with a health problem such as high blood pressure or diabetes or even expecting multiples. OBGYNs work alongside nurses to provide care and can provide various medical interventions during labor. Some OBGYN practices also have midwives on staff.
Midwives have a master’s degree and secure advanced certifications to perform midwifery care. They are focused on the physiological process of birth and can deliver babies, but do not perform C-sections. In the United States, there are various types of midwives with different credentials, but the most common are certified nurse-midwives (CNM). CNMs can practice in nearly any setting, from hospitals to freestanding birth centers and homes. Other midwives are nurse-midwives (NMs) or certified professional midwives (CPMs). Because guidelines vary from state to state, they are not as common as CNMs.
Midwives specialize in low-risk pregnancies, meaning the birthing person is in good overall health and there are no active complications that place the pregnancy at an increased risk for complications. Because most pregnancies are low-risk, midwives are a great option for those seeking a more personal approach to their care, however, only 8 percent of U.S. births are attended by midwives. Most insurance providers, including Harvard Pilgrim Health Care and Tufts Health Plan, cover treatment from CNMs and NMs, and CNMs are covered by Medicaid in all states.
A hallmark of midwifery care is understanding and addressing an individual’s social determinants of health — food insecurity, economic stability, and linguistic or cultural barriers — to provide high-quality care, which can be especially critical to those in underserved communities or women of color who experience disproportionately high negative maternal health outcomes. This holistic approach is core to midwifery and can help to promote better health outcomes for the birthing person.
Doulas are non-medically-trained professionals who support and guide women during their pregnancy and afterward. Doulas may also act as a link for the birthing person and the care team, help develop a birth plan, help manage labor, and provide pre- and post-partum support.
Doulas are advocates, serving as a proxy in times during labor when the birthing person may not be able to communicate their birth plan, or if they feel as though they aren’t being heard. However, their reach extends beyond the labor experience — they can help to schedule prenatal appointments, provide breastfeeding training, and show new parents how to care for an infant. Some insurance carriers cover doula support.
Doula support is a no-cost benefit offered to Tufts Health Plan members who receive their health coverage through Medicaid in Massachusetts or Rhode Island.
How midwives and doulas can help deliver a healthier birth experience
Extensive research has linked midwifery to positive health outcomes. For low-risk pregnancies, research published by the journal Obstetrics & Gynecology found that when compared to deliveries by OBGYNs, births handled by midwives had a 30% lower rate of C-section delivery for first-time mothers.
“Study after study demonstrates that midwifery care results in lower interventions and better health outcomes for mom and baby,” said Joyce Kimball, CPM, president of the Massachusetts Midwives Alliance. “We need to look at our health care systems to promote health via midwifery care, whether that’s through equivalent and appropriate reimbursement, additional midwifery job opportunities, easy integration into the hospital system, or full autonomy to practice.”
“I often imagine what is possible for us as a society when we design care to honor pregnant and birthing people and to ensure their experience is safe, transformational, and sacred. How babies come into the world matters for generations.”
— Nashira Baril, MPH, director of Neighborhood Birth Center
As we look to address the issues facing maternal care, the person-centered approach of midwifery could stand to make an impact on health outcomes and the way we view pregnancy and birth overall, particularly for women of color who face disproportionately poor health outcomes due in part to implicit biases within our health care system.
According to Ovia Health’s Women of Color survey, Black respondents were more likely to report not being taken seriously by their reproductive health care providers compared to their white peers, though almost half of each group felt they were not taken seriously (45% and 40%, respectively). Considering midwives’ and doulas’ approaches to care, expanding the care team to include one or both practitioners may help to support women who feel unheard or unsupported by the health care system.
Similarly, the added support of a doula can help to further educate and empower those giving birth. One study of socially disadvantaged mothers at risk for adverse birth outcomes found that doula-assisted mothers were four times less likely to have a low-birth-weight baby and two times less likely to experience a birth complication involving themselves or their baby.
“There’s a huge consequence of the failures of our current maternity care system in this country and how we have come to treat birth,” said Nashira Baril, MPH, director of Neighborhood Birth Center, a freestanding birth center in Boston that plans to open by 2023. “I often imagine what is possible for us as a society when we design care to honor pregnant and birthing people and to ensure their experience is safe, transformational, and sacred. How babies come into the world matters for generations.”
Resources for a healthy, happy pregnancy and birth experience
Finding care and support as a newly pregnant person can be overwhelming. Leveraging technology resources such as Ovia Health can help to also supplement education and guidance throughout the early stages of pregnancy. Harvard Pilgrim has partnered with Ovia to offer members access to personalized resources such as unlimited one-on-one coaches, access to lactation and behavioral health experts, and daily engagements. Through the user journey with Ovia, the app gathers information to identify if a user is at risk for certain conditions such as preeclampsia and can easily connect individuals with a provider or care manager to discuss the condition.
“It’s critical that our coaches are representative of the people we serve. Coaching sessions are offered in English and Spanish, and our team includes a variety of perspectives including Black, Hispanic, and LGBTQ-identifying individuals … ”
— Dani Bradley, MS, MPH, director of clinical services and evidence at Ovia Health
Ovia’s approach also focuses on equity and ensuring its team is positioned to address the diverse needs of its patient population. “It’s critical that our coaches are representative of the people we serve. Coaching sessions are offered in English and Spanish, and our team includes a variety of perspectives, including Black, Hispanic, and LGBTQ-identifying individuals, those who have experience using a variety of fertility services and conceived independently or as a same-sex couple,” said Dani Bradley, MS, MPH, director of clinical services and evidence at Ovia Health.
In an effort to improve safety and dignity in childbirth, Harvard Pilgrim has also partnered with Ariadne Labs and UMass Memorial Health to launch TeamBirth, a clinically proven care process innovation that launched initially at UMass Memorial Medical Center in Worcester, Mass., and UMass Memorial HealthAlliance-Clinton Hospital in Leominster, Mass., in May 2021. Two primary elements comprise the TeamBirth initiative — efforts to improve communication between the mother, the family, and the clinical care team, which include a live birth plan, storyboarding, and birth plan “huddles” between the clinical team throughout labor; and a pair of decision-making tools aimed at reducing C-sections. Lessons from this partnership will be used to establish TeamBirth as a standard of care that benefits people giving birth across New England.
If your pregnancy is low-risk and you’re interested in how a midwife or doula may support your pregnancy and birth, connect with your primary care provider and health insurer to discuss care teams, and which services are covered under your health plan. By expanding the view of maternal care by researching and integrating doulas and midwives in addition to OBGYNs, individuals can create a more holistic, comforting, and empowering pregnancy experience. Ultimately, this shift in mindset could mean better maternal health outcomes for all.
Updated November 2022:
Point32Health health plans Harvard Pilgrim Health Care and Tufts Health Plan are the first in New England and among the first nationally to achieve full NCQA Health Equity Accreditation. Learn more about our commitment to reducing disparities and improving care so all we serve can reach their full health potential: read the press release.