Midwifery Care in the United States: Increasing Access and Utilization to Improve Perinatal Health Outcomes

The United States ranks 55th worldwide for perinatal health outcomes, worse than all other similarly resourced countries. US perinatal care access increasingly is limited, and workforce burnout is high. Adverse perinatal outcomes are greater in communities with limited access to care.

This review describes the midwifery care model, associated perinatal outcomes in the United States, and historical, fiscal, legal, legislative, regulatory, and hospital policies and practices that restrict access and utilization of the midwifery workforce. Opportunities for US midwifery workforce expansion and integration are outlined.

PubMed, Scopus, and Google Scholar were searched for peer-reviewed literature, as well as historical sources and policy documents that informed this review.

Countries with excellent perinatal outcomes share similar health system characteristics, such as paid parental leave, extended postpartum care, and a larger midwifery workforce, when compared with the United States. Six critical barriers to US midwifery workforce access and utilization include limited workforce development, systemic racism and historical dismantling of the midwifery workforce, invisibility in birth certificate data, inequitable reimbursement, regulatory and legislative restrictions, and discriminatory hospital policies. Several state health care policy case studies illustrate opportunities to increase midwifery workforce expansion and integration.

The midwifery model of care is well-defined and associated with perinatal outcomes that are equal or superior to the physician model of care for low-risk women. Despite this, midwifery care is not routinely utilized or integrated in standard US perinatal care systems due to current restrictions. Addressing these restrictions will improve the delivery of US perinatal care and associated outcomes.