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Call the Midwife: Transforming Maternal Health through Managed Care

Midwives role in the US's healthcare system

Published February 3 2025

Analysis by Ann Lundstrom


Mothers are dying. The US shamefully has the highest maternal mortality and morbidity rate of any developed nation, being one of the only two countries worldwide that have seen a significant increase in maternal deaths since 2000 (1).  In response, there have been several policies enacted that strive to lower these deaths, such as the American Rescue Plan Act of 2021 (ARP), which expands postpartum Medicaid coverage from 60 days to 12 months for the states that choose to accept the expansion. However, several states have chosen not to implement this or other expansions (2). Overall, though, these policies have contributed to a decline in maternal mortality (3). But this is far from enough. Rather than just providing insurance, it’s time to target the system. 


The system begins with access to healthcare. One glaring issue contributing to maternal mortality rates is the limited access to health care in rural and unserved areas. An article published in Clinical Obstetrics and Gynecology states that though there are shortages in medical professionals everywhere, “these shortages are more severe in rural areas, where half the counties do not have hospital obstetric services, nor do they have a single OB/GYN or CNM”(4). With such a shortage, it would be difficult, verging on impossible, to fill the need. Yet, the solution may already exist. We just need to utilize it. 


Midwives have been a consistently underused and overlooked resource in the medical field. This partially stems from regulatory barriers and an inability to receive reimbursement from private insurance and other third-party payers.(5) The chafing bureaucracy prevents midwives from effectively delivering care within their scope of practice. Yet, an editorial published by The New York Times asserts that midwives have the potential to substantially increase quality of care within obstetrics (6).  Specifically, midwives can target complications arising from preexisting medical conditions, which is one of the main risk factors in maternal health. Many of these women are unable to access care and support for both their conditions and their pregnancy (1). This lack of care leaves women isolated and vulnerable, something that midwives can address. 


Midwives, with their education and professional flexibility, can open up doors for those who may not be able to regularly receive health care services. As highly trained medical professionals, they not only have training in labor and delivery, but they are also valuable resources for new parent education and prenatal and postpartum care (7). Standardizing midwifery practice throughout the U.S. and reforming the autonomy of their care can not only yield improved perinatal outcomes, but also decrease costs due to fewer hospitalizations and interventions (5). This would have considerable benefits in transforming accessibility and affordability of the expensive and difficult process that mothers go through. 


But how do we go about incorporating midwives into the system? Well, we need to work within the structural framework already provided. Medicaid operates primarily within managed care systems, with about 90% of Medicaid beneficiaries enrolled in managed care

(8). Managed care systems control healthcare costs and quality by coordinating patient care through a network of providers. By establishing midwives as a larger part of these provider networks, the women who receive Medicaid for pregnancy and postpartum periods will have access to a comprehensive care system focused on supporting them in their maternal health journey. This would benefit mothers no matter if their state accepted or declined the Medicaid expansions offered in the ARP 2021. Many midwives continue care well into the postpartum period and offer support for future pregnancy plans as well, which has proven to lead to high patient satisfaction (9). As mentioned previously, a main advantage of midwives is their location flexibility. Midwives are able to work in hospital settings as well as hold consults and appointments at the patient’s house, increasing the quality of care and access within the managed care systems. Rather than managed care systems providing resources that these patients must find and travel to, the resources can come to them. 


By addressing these regulatory barriers and shortages of medical professionals, we can start to fully embrace the potential of our midwives. It’s time to move beyond piecemeal policies that, while targeting maternal mortality rates, have failed to actually reform the broken system. Midwives offer the opportunity to focus on a systemic change that will give the women of our country the access and quality of care that they need to thrive. Our nation's mothers deserve nothing less than comprehensive, compassionate healthcare that prioritizes their well-being and celebrates the invaluable role of midwives in our communities. Let's not just lower the maternal mortality rates—let's transform them.



  1. Wang, Siwen, Kathryn M. Rexrode, Andrea A. Florio, Janet W. Rich-Edwards, and Jorge E. Chavarro. “Maternal Mortality in the United States: Trends and Opportunities for Prevention.” Annual Review of Medicine 74, no. 1 (2023): 199–216, https://doi.org/10.1146/annurev-med-042921-123851.

  2. Adashi, Eli Y., Daniel P. O’Mahony, and I. Glenn Cohen. “Maternal Mortality Crisis and Extension of Medicaid Postpartum Coverage.” JAMA 330, no. 10 (2023): 911. https://doi.org/10.1001/jama.2023.15380.

  3.  National Center for Health Statistics. “Maternal Mortality Rates in the United States, 2022.” Accessed November 25, 2024. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.pdf. 

  4. Garcia, Kelly K., and Stephen K. Hunter. “Proposed Solutions for Improving Maternal Health Care in Rural America.” Clinical Obstetrics & Gynecology 65, no. 4 (2022): 868–76. https://doi.org/10.1097/grf.0000000000000754

  5. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, et al.. “Mapping Integration of Midwives Across the United States: Impact on Access, Equity, and Outcomes.” PLOS ONE 13, no. 2 (2018): e0192523. https://doi.org/10.1371/journal.pone.0192523. 

  6. Gillispie-Bell, Veronica. “More Mothers Are Dying. It Doesn’t Have to Be This Way.” The New York Times. July 16, 2023. https://www.nytimes.com/2023/07/16/opinion/reduce-maternal-mortality-strategies.html. 

  7. Mayo Clinic College of Medicine and Science. “Nurse Midwife - Explore Healthcare Careers - Mayo Clinic College of Medicine & Science.” Accessed November 22, 2024. https://college.mayo.edu/academics/explore-health-care-careers/careers-a-z/nurse-midwife/#:~:text=Providing%20prenatal%20and%20postpartum%20care,delivering%20the%20newborn%20and%20placenta.

  8. Medicaid and CHIP Payment and Access Commission. “Managed Care Overview - MACPAC.” Last modified October 16, 2019. https://www.macpac.gov/subtopic/managed-care-overview/. 

  9. Combellick, Joan L., Michelle L. Telfer, Bridget Basile Ibrahim, et al. “Midwifery Care During Labor and Birth in the United States.” American Journal of Obstetrics and Gynecology 228, no. 5 (2023): S983–93. https://doi.org/10.1016/j.ajog.2022.09.044.

 


 
 
 

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