The Maternal Health Task Force’s Kayla McGowan recently had the pleasure of interviewing Saraswathi Vedam, Principal Investigator, Birth Place Lab, and Associate Professor, Division of Midwifery, Faculty of Medicine, University of British Columbia about her innovative study assessing the integration of midwifery across the United States (U.S.).
KM: Your recent study, Mapping integration of midwives across the United States: Impact on access, equity, and outcomes, published in PLOS ONE took a first-ever look into the status of midwifery care in the health system and birth outcomes in every U.S. state. What drove you and your team of epidemiology and health policy researchers to conduct this research?
SV: The idea for the AIM Mapping study started at a multi-disciplinary meeting we had back in 2011, the Home Birth Summit, where we had leaders from all kinds of perspectives, including clinicians—doctors, midwives and nurses—as well as health administrators, liability specialists, insurers, policymakers and researchers. Most importantly, we had an equal representation from consumers themselves and consumer advocates, so we had the whole system in the room—everybody for whom these issues of birth place have relevance. We realized that we were really talking about the whole maternity care system. There were many cross-cutting themes wherever people delivered.
KM: And what came out of that meeting?
SV: We found that a key challenge to delivering high quality care was the degree of integration, meaning the degree of communication and collaboration and systems that facilitated smooth transition from one setting to another or one provider to another or one system to another—that’s where the areas of disconnect, disarticulation and sometimes conflict often were.
Our team—consisting of research, regulation/licensure and consumer experts—believed that if we could first define what we meant by integration, then we could start to see if there was a connection between model of care and outcomes.
KM: Your team ranked each state according to the Midwifery Integration Scoring System (MISS), which measured scope of practice, autonomy, regulations and other indicators related to midwifery regulation, to get an evidence-based picture of the level of access to midwifery care in the context of state health systems. What were some of the states with both high and low scores? Were there any regional trends?
SV: We found that there was a range of state integration scores from 17-61, but the total possible score was 100 points, so no state in the U.S. got a really high score. Across the states, Washington, New Mexico and Oregon had higher scores, while South Dakota, Alabama, North Carolina had the lowest scores. You can find an individual state score by looking at their report card on the website for my lab.
As for regional trends, it depends on the outcome that you are looking at, but in general, the highest quartile of scores and optimal outcomes were in the Pacific Northwest, New Mexico, New York and some places in New England. Generally speaking, the Southeast had the lowest scores and worst outcomes, but again, it depends on the outcome you are interested in.
KM: What were the most important findings related to MISS scores and maternal and newborn health outcomes? Was any of this surprising?
SV: The findings line up with international data (from The Lancet Series on Midwifery and Cochrane systematic review of midwife-led care). The U.S. is later to analyze this and has lower utilization of midwives as part of the health system compared to other high-resource countries. Other high-resource countries in which midwives have a more active role in the health system benefit from better outcomes. Studies have shown that when midwives are part of the system, there is a clear trend toward increased cost-effectiveness, and fewer interventions. Very serious outcomes such as preterm birth and mortality also seem to reduce, and it seems to be true whether or not you are looking at low-risk populations.
Our findings are not surprising considering what has been shown for midwifery care globally. It’s not a big surprise to see that there were higher rates of breastfeeding, lower rates of preterm birth, lower rates of cesarean sections or induction, higher rates of spontaneous vaginal delivery and lower rates of neonatal mortality in states where integration of midwives was high.
When you look globally, when midwives are involved in the care, everybody benefits, including those with moderate or greater risk factors for complications. It’s not that midwives are necessarily better at providing acute care, it’s that the model of care allows for more relationship-based care and more continuity. People tend to have more of a longitudinal relationship with care providers and are more likely to share information that allows for prevention or treatment. It’s not a zero-sum game. It’s not midwives or doctors or midwives or specialists or family doctors or obstetricians—when everybody collaborates, when everybody is part of the system offering care, both outcomes and experience improve.
KM: How might better integration of midwives in the U.S. address persistent racial disparities in maternal health—in which African American women experience a two to four times higher risk than white women for both maternal and infant mortality?
SV: We realized that integration of midwives is not the whole story with respect to health disparities, so we looked a little further. Maternal and fetal wellbeing are affected by a complex set of inter-related factors, so, since. there has been a lot of discussion in the literature and press about the differential increased rates in adverse outcomes that African American families are experiencing in the U.S, we decided to focus on race. We found that states that reported higher rates of black births were also the states with poorer birth outcomes and lower integration. We wanted to discover how much of those differences in outcomes were accounted for by race alone, and how much of those differences could be accounted for by the degree of integration. After controlling for the effects of race, we found that about 38% of variance in outcomes could be accounted for by race alone. An additional 10-12% of the improvement in outcomes could be accounted for by the degree of integration of midwives. That is, if midwives were part of the system, outcomes such as preterm birth, neonatal mortality and breastfeeding improved by an additional 10-12%. It doesn’t tell the whole story, but it tells an important part of the story.
KM: The study found that states with higher MISS scores had a greater concentration of midwives per state and higher proportions of midwife-attended births across settings. How might states with lower MISS scores adapt to follow this model?
SV: Midwives want to practice to their full ability, so many are going to set up practices in places where they are able to do that autonomously. States that have lower integration scores and concomitant low density of midwives could maybe look at developing local midwifery education programs as well as looking into their statutes and regulations—and their interpretations—to see how those are creating barriers to practice and access across populations.
KM: Findings from this study also informed an interactive map providing data on midwifery integration, as well as density of midwives, and access to midwife attendants across birth settings by state. What are the next steps in implementing these findings and tools?
SV: We encourage people to explore the interactive map and state report cards to understand the impact of regulation in their own communities. We hope that this analysis will help to inform initiatives to improve access to and integration of all maternity providers across settings.
It’s important to consider that regulations are constantly changing, and these tools are based on statewide data. The AIM Mapping Study findings can support evidence-based development of a regulatory and practice environment that supports interprofessional collaboration, and consequently better health for families.
KM: What are the implications for maternal and newborn health in the U.S.? Are there any key takeaways that can be applied to maternal and newborn health in other areas of the world?
SV: The key implications are that access to midwifery care has to be part of the conversation whenever we are looking at maternal and newborn health outcomes anywhere in the world. By applying the International Confederation of Midwives’ standards on a country-by-country basis, along with the MISS scoring system, we’ll start to understand how we can better utilize midwives to address some of the most challenging problems in maternal and newborn health.