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US Families Could Benefit From Integrating Midwives

Lynsey Hamilton – Knowledge Translation Specialist, Birth Place Lab Midwifery Program, USA

It is well established that the level of coordination between care providers and across birth settings has a strong impact on health and wellbeing of mothers and babies. A new study, the Access and Integration Maternity care Mapping (AIMM) study, led by Prof Saraswathi Vedam at the Birth Place Lab at University of British Columbia, demonstrates that maternal and newborn outcomes are linked to how well midwives are integrated to the health care system. This recent study reviewed state laws and consulted experts from all 50 states in the US to describe the current maternity care system.

Using a formal decision making (Delphi) process, the multi-disciplinary research team developed the Midwifery Integration Scoring System (MISS), to describe the role of midwives in state health care systems.  The MISS system considers 7 aspects of the regulatory environment that affect autonomy, scope and site of practice for midwives; the ability of midwives to access and administer medications; availability of insurance coverage; and the ease of referral to medical specialists.  In the AIMM study, the researchers calculated MISS scores for all 50 states and the District of Columbia.  Based on 50 indicators of level of integration, each state was assigned a score out of a maximum of 100.  Washington State is the highest at 61, North Carolina is lowest at 17. These state scores reflect how laws, and local interpretation of laws, can affect the ability of families to access the care they need over the course of pregnancy and birth.

Next, the researchers linked state MISS scores to 9 key maternal and newborn outcomes in each state using data from the Centers for Disease Control Vital Records.   The study shows that states with higher MISS scores report better outcomes for mothers and babies such as vaginal births, VBAC and breastfeeding, and lower rates of caesareans, premature birth, and neonatal death.

The research team created a series of online interactive maps that allow you to explore these linkages yourself at a national and state level. The maps show a variety of health indicators overlaid on maps of Integration, Access to Place of Birth and Density of midwives. There is also a map showing where black families give birth and experience worse outcomes, how that relates to areas where midwives are not part of the system. The website includes a brief video explaining the maps in detail.

Map showing Integration of Midwives (higher integration is darker shades of purple, lower integration is lighter shades) with states with the lowest levels of neonatal mortality outlined in green and those with the highest rates of neonatal mortality outlined in red.

In addition, the study team created a report card for every state that shows its MISS score and national ranking, and how the maternal and newborn outcomes in each state compare to national averages. These report cards provide information on some of the factors that make up the MISS score including licensure, prescription writing authority, ease of access to medical referral, and Medicaid reimbursement for each of the three types of midwife that currently practice in the US.

An example of the State Report Card


The team hopes that policymakers and clinicians will be able to utilise these tools to inform the development of a more integrated maternity care system, to ensure that all families can access high quality maternity care wherever they plan to give birth.

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