Let’s Midwife the System

Honestly, it may be our only hope.

Amy Romano
Oct 18 · 4 min read
Woman holding newborn baby with midwife by her side.
Woman holding newborn baby with midwife by her side.
Photo: @kayp via Twenty20

We need a new maternity care system in the United States.

The one we have is irreparably broken, scarred by a history steeped in misogyny and white supremacy, where women’s bodies have been subject to involuntary experimentation, obstetric violence, and a parade of interventions proven to cause harm only after decades of being hailed as standard practice — interventions ranging from DES and Thalidomide, to twilight sleep, routine episiotomy, and the still-entrenched continuous electronic fetal monitoring debacle.

It’s no wonder our maternity care system produces dismal results.

In the United States we have the highest maternal and infant mortality rates among industrialized countries, widening racial disparities, no access at all in a majority of rural areas — all for the highest price-tag in the world.

To say “our maternity care system” is a misnomer in the first place. The word “system” implies that somehow it has been designed or engineered to achieve certain health outcomes (it hasn’t), or that there are certain standards for how care is organized and delivered (there aren’t).

There is very little that is designed or standardized in our fragmented, poorly performing maternity care system. The dominant care delivery model — 12 or so doctor visits per pregnancy, confinement to a hospital bed for labor and birth, minimal opportunity for education, separate medical appointments for moms and babies after birth — this has all just been passed down as the way it’s always been done, and became the way things are done during our fraught history, without evidence, and against the protest of midwives.

Midwives were the dominant maternal and newborn practitioners throughout almost all of human history.

Midwives have been the experts on pregnancy, birth, and postpartum and newborn care for over a million years, all the way up until the early 20th century in the United States. Then came a profit-driven campaign to pathologize pregnancy and childbirth, silence midwives, and move birth out of the realm of family and community and into the four walls of the hospital.

Despite being marginalized, maligned, and misunderstood, midwives have continued to provide primary, community-integrated maternity care for families throughout each problematic period in our history of modern maternity care, persisting despite a range of regulatory environments that have made it anything from impractical to illegal to practice in a community-based midwifery model.

Midwives also continued to dominate the maternity care workforce throughout the 20th century in nearly every other country around the globe, modernizing the profession and integrating community-based midwifery models with physician practices and hospitals to coordinate care across the risk spectrum.

Midwives and midwifery practices are credited with playing a key role in substantial reductions in maternal and infant death seen worldwide during the same eras in which American rates plateaued or increased. In fact, on the heels of a 2014 Lancet series that identified continued large opportunities to reduce mortality and morbidity rates globally through expanded use of midwives, The World Health Organization has designated 2020 The Year of the Nurse and Midwife.

Seriously, we need a new maternity care system in the United States.

One that reliably provides access in the communities where people live and work.

One that upholds fertility, pregnancy, childbirth, and the postpartum period as whole-person, whole-family experiences.

One that educates, activates, and empowers people and invites shared decision making.

One that elevates the role of the community and society in promoting and protecting the health of women and infants.

One that fights and dismantles misogyny, racism, homophobia, and all forms of bias and injustice.

One that works towards families thriving, not just surviving.

One where women and babies, especially black women and babies, aren’t dying every day of preventable complications.

Let’s midwife the system.

Yes, that means growing the midwifery workforce and making midwives more accessible and integrated. But it also means putting the components of the midwifery model into more widespread use, regardless of who is delivering care.

I never cease to be amazed at how often the latest “healthcare innovation” is something midwives have been doing all along. Over recent years, ACOG has issued a series of practice recommendations and toolkits that promote supportive care, shared decision making, and reduced use of interventions, such as labor augmentation, cesarean delivery, and immediate clamping of the umbilical cord. I’ve hailed these developments — it’s amazing progress from their previous conservative stances, and we need their leadership on this.

But let’s be clear on who led the creation of research evidence and practice standards they now espouse. In many cases, it’s been midwives, and investigators studying midwife-led care systems.

You see this even in the broader healthcare system, outside of maternity care. If you go to any healthcare innovation conference, the kinds of newfangled ideas you will encounter are things like home visits, group visits, moving care outside of the hospital, interprofessional collaboration, addressing social determinants of health, implementing shared decision making, or addressing lifestyle and behavior.

(Midwives, do any of these things sound familiar? It’s all the stuff we already do! We just are used to calling it “the midwifery model.”)

Midwives have only recently gained a seat at the tables shaping our healthcare system. A century of marginalization leaves major power imbalances and structural forces still intact, but midwives know persistence and resilience and creativity and team building — these are foundational to supporting people through pregnancy, birth, and postpartum. They are the qualities we work to foster through our care, and that we are privileged to see on full display when our informed, empowered, activated clients give birth and take on new parenthood, or any of life’s other journeys.

These are also qualities that make us good leaders. So let’s midwife the system.

Amy Romano

Written by

Midwifing the system.


A conversation about the future of parenthood by Motherly

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