Expert Q&A: Cutting midwife services hurts lower-income, marginalized populations most

Ascension Health recently announced that it would eliminate midwife care from its Alternative Birthing Center in Southfield, Michigan, despite increased demand for services in the state—a demand that follows a national trend.

Lisa Kane Low, Ph.D., CNM, FACNM, FAAN, is a professor at the U-M School of Nursing and a midwife whose research focuses on optimal childbirth experiences. She discusses what this decision means for the profession and for women in Michigan.

Why might someone choose a midwife over a physician?

Usually it is a desire for personalized supportive care that is focused on promoting a healthy physiologic labor process. It may also mean access to additional safe, quality ways to provide comfort during labor that are in addition to access to usual medications. Examples include waterbirth, care in a birth center or home birth, in addition to the option for hospital care as necessary. Midwives also have a philosophy of care that encourages education, shared decision making and partnership in the care process that engages the birthing family and their support system.

What does this mean for Michigan?

Access to midwifery care has been growing throughout Michigan, and other health systems have added midwives to their teams. An example of the demand is that all the midwives who were given a 30-day notice at Ascension Providence all have new positions at other health systems or programs now. The issue, though, is that the population served at Ascension Providence is being denied access to midwifery care.

As an aside, another Ascension system hospital, Borgess in Kalamazoo, did a similar thing and discontinued the midwifery service that was in place over a year ago, (but) is now exploring how to hire back midwives after they saw the gaps in care that existed. Sort of a pennywise and pound-foolish approach.

What does this mean for the profession?

Midwives losing jobs or roles due to financial competition is not new, it just remains unfortunate, particularly in this time when we know that there are rising rates of maternal mortality. The integration of midwives into the health care system and team has been documented as a positive intervention to address these challenges. At a point in time when midwives are increasing in number and there is growing demand for their care and services, it is an odd decision to move away from having them when they have been a strong resource and provider of care previously.

Who will be most affected by this?

Over and over again it is marginalized populations, often served by Medicaid, that have the least portability in care. Also, when travel barriers are present, like a lack of public transportation to new sites for clinical care or long distances to get to services, then those families are essentially left out of having access as well. Programs like Birth Detroit are also an example where they are launching a birth center and have ready-access prenatal care clinics, which are all building midwifery care access in the city of Detroit because there are so many barriers to accessing care within health systems.

How does last year’s Supreme Court decision to overturn Roe v. Wade factor in here?

We will have more families who are losing choices, being limited in access and also being forced in some areas to proceed with a pregnancy that they would otherwise have not continued. All of these factors contribute to higher rates of maternal morbidity and mortality.

The CDC just released a report documenting that the rates increased in 2021-2022 during a period of time when more resources have been focused on emergency care for birthing families. This points to two key challenges: First, we seem to be fixing the wrong problems; we are too far downstream in the pregnancy care cycle with our emphasis on emergency care and not enough resources going upstream to prevent the emergencies from developing in the first place.

We also need new and improved ways of providing maternity care in general. We have a system dominated by physician care in large-scale health care systems and hospitals. Evidence based alternatives are available and yet they are not supported. We also continue to have obstetric racism and structural racism that permeates the ways maternity care is delivered.

We must change both of these to make a difference. We cannot keep doing things the same old way. While we do need a strong, diverse physician workforce, we also must invest in a diverse midwifery care workforce that can provide safe, quality care in other settings outside of the transitional maternity care delivery unit.