The United States is one of the most dangerous places to give birth in the industrialized world, with maternal mortality rates rising over the last few decades. With that in mind, it is critical to understand the relationship between access to care and overall outcomes. Overall, black women are two to three times more likely than white women to die during pregnancy or childbirth. These discrepancies also apply to newborn health outcomes. Enhancing access to care, including care from various providers such as midwives and doulas, reduces inequities and improves maternal health outcomes. 

Unfortunately, the United States does not practice midwifery as often as other nations and cultures do, even though having a midwife improves the outcomes of childbirth. 

Despite, and arguably, what appears to be a robust healthcare system, in 2020, the March of Dimes found that 1,095 counties in the United States lack maternity care (no hospital offering obstetric care, no birth center, and no obstetric provider). That included 57 counties in Missouri and 76 in Kansas. These maternity care deserts span urban and rural areas of the country. A report from the federal Centers for Medicare and Medicaid Services (CMS) found that counties with more significant proportions of black and Hispanic populations and those with an overall lower median income were more likely to lack a hospital with obstetric services. 

Linda Marsa, “Labor Pains: The OB-GYN Shortage,” found that a midwife workforce, integrated into health care delivery systems, could provide 80 percent of essential maternal care around the world and potentially avert 41 percent of maternal deaths, 39 percent of neonatal deaths, and 26 percent of stillbirths. Midwives could also help address the workforce shortages that loom large in the U.S. maternity care landscape: nearly half of U.S. counties lack a single obstetrician-gynecologist, and it’s estimated that the nation needs 8,000 more to meet demand—a number that, by one estimate, may rise to 22,000 by 2050. 

An ideal maternal health system would provide all women with complete and seamless medical care, as well as access to necessary behavioral, economic, and social support before, during, and after their pregnancy. Access to maternal health care in rural communities is limited due to many different factors. Creating an ideal maternal health system involves, among other things like legislation, regulation, federal funding, and equitable Medicaid reimbursement, the full integration of midwives into the maternity care system.

Given the many benefits of midwives and the significant maternal care disparities that afflict black and Indigenous families in the United States, it is vital to explore how they might be better incorporated into the healthcare system. It includes the deliberate integration of midwifery into the complex healthcare ecosystem to ensure that midwifery care is accessible, inexpensive, and equitable to all childbearing individuals. 

Kim Onile, CPM, B.A., J.D., of Onile Midwifery, highlights the changes in community-level care and how she holistically approaches the pregnancy and childbirth continuum, focusing on relationships. 

Onile grew up in the Kansas City area with parents who served in the military. Her upbringing reinforced the belief that she can do anything and everything possible; nothing is off-limits to her. 

As a mother of four, she initially did not plan on motherhood being part of her early journey. Her experiences provided a lot of variety, from different providers to health considerations, life circumstances, actual births, and postpartum experiences. 

Her second pregnancy resulted in an emergent birth situation, which was what influenced her to go toward natural, holistic providers for more positive experiences with her third and fourth births. 

Onile’s passion for addressing perinatal health disparities stems from her belief that equitable outcomes can be achieved through a particular approach to care. She has witnessed firsthand the positive impact of treating patients with respect and empowering them to make informed decisions about their health. 

Because of Onile’s experiences, she discovered her passion, and it was not law. After receiving her bachelor’s degree and starting law school while pregnant for the third time, she left school. She realized her passion wasn’t in law but helping women feel confident, informed, and empowered with their birth experiences. She had always known she wanted to make changes in the community, and that’s precisely what she does as a midwife. 

“My passion, still to this day, is rooted in improving the circumstances for people on the ground. So, at every step of accomplishment, whether it was getting through undergraduate or law school or becoming a midwife, the underlying theme was, How can I make the biggest impact on people’s lives on the ground?” 

In midwifery, a practitioner’s effectiveness often hinges on their ability to establish meaningful connections with their patients. Understanding this, practitioners like Onile prioritize individualized care, recognizing the profound impact of personalized support on patient outcomes. By taking the time to truly see, hear, and empower their patients, midwives facilitate an environment where informed decision-making flourishes, ultimately leading to more positive birthing experiences. Onile hears, “You see me. You hear me. You understand me. You don’t tell me what to do. You give me information and help me make informed decisions I feel good about, and then you support me.” 

To address the broader landscape of maternal health, midwives advocate for comprehensive support structures beyond traditional medical care. Emphasizing the importance of collaborative networks, they advocate for including various healthcare professionals, such as obstetricians, doulas, therapists, and nutritionists. This multifaceted approach ensures pregnant individuals receive holistic support tailored to their unique needs and circumstances. 

Despite advancements in healthcare, perinatal health disparities persist, disproportionately affecting marginalized communities. Midwives recognize the systemic barriers contributing to these disparities and strive to provide culturally competent care. By acknowledging and understanding their patients’ diverse backgrounds and experiences, midwives work to bridge gaps in care, fostering trust and understanding throughout the birthing process. 

In addressing these challenges, midwives emphasize the importance of open communication and patient-centered care. Midwives create environments where patients feel valued and supported by engaging in meaningful dialogue and empowering patients to make informed choices. Through their dedication to inclusive and culturally competent care, midwives are vital in promoting equitable health outcomes for all pregnant individuals. Onile declared, “The best outcome, at the end of the day, is a healthy mom, a healthy baby.”

Onile emphasizes that people in these communities do want care. Still, they may turn away from traditional medical establishments due to past negative experiences or a desire for alternative care methods. Midwifery, chiropractic care, and other holistic modalities are alternative approaches that some individuals find more aligned with their values and beliefs. However, these alternative care methods are often not considered valid or covered by insurance, limiting access for those who would benefit the most. 

She believes the key to addressing perinatal health disparities lies in providing personalized care to each patient. She emphasizes the need for healthcare providers to engage with patients and work together to achieve the best outcomes based on the patient’s individual needs and preferences: “This approach does not necessarily require more resources or specialized training, but rather attention and intention in providing compassionate care.” 

While doctors and hospitals are working towards making their practices more accommodating and compassionate, traditional medical establishments still have limitations. Midwives acknowledge that change within the traditional medical establishment can be slow and challenging. The bureaucratic nature of large healthcare systems often hinders progress in addressing disparities. Despite the efforts of some healthcare providers, there will continue to be individuals who feel that the care they receive is not good enough. 

 Looking Ahead: Progress and Advancement 

In terms of progress and advancement, Onile hopes to see midwifery care covered by all types of insurance, including Medicaid—currently, the lack of insurance coverage limits access for those who would receive help. Expanding insurance coverage for midwifery care would allow midwives to provide care to more people and contribute to reducing perinatal health disparities. 

Midwives play a crucial role in addressing perinatal health disparities by providing personalized and compassionate care to marginalized communities. Existing systems of care have created and perpetuated inequities in healthcare service delivery and have resulted in grave disparities in health outcomes. To effectively provide care to black and Latino women, the U.S. must establish systems of care that are equitable and culturally relevant by acknowledging the value of traditional birthing practices and addressing racism, discrimination, and bias. Culturally diverse midwives have been a critical piece of the care puzzle for birthing people in the U.S. Still, traditional birth work has been systematically degraded as birth has become increasingly medicalized. The marginalization of midwifery, cultural research, and holistic care knowledge must be undone. 

Healthcare providers and policymakers must join forces to ensure midwives have access to a robust healthcare system, enabling them to deliver safe, woman-centered, personalized care rooted in evidence-based research. Also, there’s a crucial need to enhance the integration of research, education, and health services to elevate existing primary healthcare programs, thereby enhancing the quality, accessibility, and impartiality of maternal and newborn health for all demographics. The abundance of evidence and statistical insights on racial disparities in maternal mortality underscores the urgency for proactive legislation, offering a comprehensive understanding of the issue while enhancing care quality for black women and women of color. 

That underlines the necessity of a comprehensive policy framework aimed at ending racial disparities in maternal and neonatal health. Prioritizing the availability of midwifery care, covered by insurance, is pivotal in striving for equitable outcomes, ultimately reducing perinatal health disparities and fostering the well-being of marginalized communities.