By Jessica English, LCCE, FACCE, AdvCD/PCD/BDT(DONA)
Last week, physicians at Ascension Borgess Hospital in Kalamazoo made the decision to cut the number of midwives in their practice from seven midwives to three. This is a frustrating, troubling change for our community, and it will limit midwifery options for area families, setting us back in decades of progress in Southwest Michigan. We’ve been gathering information about the change, and here’s what you should know.
In most countries around the world, midwives are the default provider and the standard of care unless there is a serious complication.
Slashing the number of midwives and making physician care the default at Ascension Borgess isn’t a sustainable or desirable strategy for our community. We appreciate the expertise that physicians bring to the maternity care system, but midwifery care is the ideal and it should be the norm, with physician backup for complicated medical problems. Kalamazoo has always been a leader in the number of midwives caring for families. Why are we suddenly going backward?
Consider the case for midwifery as the default care option for families.
You’ll get more respectful care and more options from a midwife. As doulas, we see a variety of care providers in many settings. With few exceptions, midwives offer the most respect for autonomy of the person giving birth, as well as offering more options and perspective. In their research The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States, Vedam et al found: “Protective factors, in terms of mistreatment were: being White, having a vaginal birth, giving birth at home or in a freestanding birth center, having a midwife as the primary prenatal provider, and having a baby after 30 years of age.”
Given that racism is a risk factor for mistreatment and Kalamazoo has a high rate of disparity in maternal and infant outcomes, it’s especially important that we have as many other protective factors in place as possible.
Here’s what we’ve observed from the hundreds of births we attend each year. Want to give birth standing next to the side of the bed? Your midwife is much more likely to sit on the floor to catch your baby. You’re also more like to get enthusiastic support from a midwife for other positions like kneeling, hands and knees, a full squat, or sitting on the CUB chair to deliver your little one. (And that’s not just a comfort or “experience” issue for you, it can be the difference in having a vaginal birth or a cesarean.) Planning to opt out of an IV or hep lock for your low-risk birth? Midwife. Want intermittent monitoring with a Doppler? Midwife. Declining vaginal exams? Midwife. Need someone to sensitively navigate your trauma from life experiences or a previous birth? Midwife. Midwife, midwife, midwife.
You’ll experience better outcomes with a midwife, and it’s an equity issue. Whenever people tell us they want a low-intervention birth, we encourage them to seek care with a midwife. The Cochrane Review offers a 2016 meta-analysis of midwifery care. The review of 17,674 births found that people who had midwifery care were less likely to have an epidural, an episiotomy, or an instrumental birth (vacuum or forceps). They were also less likely to experience pre-term birth and at a lower risk for stillbirth. Again, in a community with high disparities for Black families, including preterm birth and loss, it’s crucial that families receive midwifery-led care. The Cochrane Review found no adverse effects with the midwifery model of care compared with other models.
Further, a 2018 scoring review by Vedam et al found that states that had a higher integration of midwives using their “Midwifery Integration Scoring System” (MISS) had “significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. ... Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.”
For even more information and citations, check out the American College of Nurse Midwives’ summary of research on midwifery care in the United States, and the March of Dimes Position Statement on Midwifery Care and Birth Outcomes in the United States.
Cost is an issue, you say? Health systems save more by using midwives.
Midwifery care is less expensive. The midwives at Ascension Borgess have been told by physician leadership that the cuts to their support are due to declining patient numbers related to Covid-19. But that reasoning doesn’t make sense, given that midwifery care is significantly less expensive than physician care. Ascension Borgess could save more money by making midwives the lead care givers for pregnancy, labor and delivery, with physicians on call at home in case of complications. A 2019 policy brief from the Minnesota School of Public Health concluded that "Increasing the percentage of pregnancies with midwife-led care from the current level of 8.9% to 20% over the next 10 years could result in $4 billion in cost savings..."Now in Kalamazoo, the percentage of midwifery-led births is higher than 8.9 percent. In 2017, Altman et al examined The Cost of Nurse-Midwifery Care: Use of Interventions, Resources, and Associated Costs in the Hospital Setting. The authors wrote, “This study supports consideration of increased use of CNMs as providers for the care of women at low risk for complications to decrease costs for the health care system. The use of CNMs to the fullest extent within state-regulated scopes of practice could result in more efficient use of hospital resources.”
Why would Ascension Borgess cut the more economical provider option in favor of more expensive physician-led care? The numbers don’t add up for families or for hospitals.
As doulas and childbirth educators, we are in touch with families from around Southwest Michigan. We excel at listening and assessing needs. Families tell us they want midwifery care. We want midwifery care.
It may not be possible to reverse these changes, but “the powers” should at least hear the voice of our community. We care deeply about the midwives, nurses and physicians at Ascension Borgess Hospital and we want them to thrive long into the future.
We understand that Ascension Borgess is not eliminating midwives, but these changes will limit options for families and they are not the right direction for our community. Midwifery is the way.
Please reach out to Ascension Borgess to share your thoughts. A specific ask might be that they reconsider the midwifery cuts and for both economic and safety reasons make midwives the primary care givers in the office and in the hospital with physician backup/call from home as needed.
Phone: 314-733-8000 (Ascension national hotline to record comments)
Dr. Frink: Jennifer.Frink@ascension.org
Dr. Schugars: Sara.Schugars@ascension.org
Dr. Kindler, clinical Dyad leader: email@example.com
Cheryl Gueldenzopf, regional president: Cheryl.Gueldenzopf@ascension.org
Dr. Thomas Rohs CMO: Thomas.firstname.lastname@example.org
Kalamazoo deserves midwifery care as the integrated and honored primary option — not as a second thought.