By Annalisa (Nalis) Merelli is a general assignment reporter at STAT.
A midwife checks the heartbeat of an unborn baby on the antenatal ward at the Lancashire Women and Newborn Centre at Burnley General Hospital in Burnley, north-west England.
In the wake of growing alarm over the disproportionately high rates of maternal mortality in the U.S., maternal health experts have been pushing for changes — including expanding the midwife workforce. Studies have shown that deliveries attended by midwives tend to have fewer complications and better outcomes, partially because midwife training relies less on medical intervention, leading to fewer C-sections.
The number of credentialed midwives — including both certified nurse-midwives, who can attend births in hospital settings, and a minority of certified midwives, who don’t hold a nursing degree — in the U.S. more than doubled from 1991 and 2012 and has continued to grow steadily in the years since. Universities have also expanded their course offerings, with the number of new students enrolled in accredited midwifery programs growing from 1,006 students in 2014 to 1,214 in 2018, according to the latest data available.
Yet the workforce continues to be not only small, but racially homogenous: More than 90% of midwives are white.
“Depending on what you look at, there are somewhere between 7,000 to 15,000 midwives overall within the United States, but […] only 4.9% of that entire number are African American,” said Gina Brown, the dean of Howard University’s College of Nursing and Allied Health Sciences.
Because racially concordant care is associated with better outcomes, adding diversity to the midwife cohort is an important piece of the puzzle in reducing maternal mortality, which affects Black women at almost three times the rates of white women. Black midwives and midwives from other underrepresented racial and ethnic groups are also more likely to serve in their communities of origin, providing a service where the maternal mortality emergency may be more acute.
But because of challenges including the high financial costs of a midwife education and the difficulty of finding placement opportunities for midwives in training, diversifying the midwife workforce isn’t a simple task.
The problem of clinical placement
Some educational institutions are trying to expand and diversify their midwife student cohort by partnering with historically Black colleges and universities that don’t have the resources to offer the expensive midwifery training. New York University’s Rory Meyers College of Nursing, for example, entered a partnership with Howard University in 2021 and is working to raise the funds necessary to support midwifery training for Howard students and alumni, who can then return to practice in their communities of origin.
But being able to enroll more midwifery students from underrepresented groups is only one part of the issue. The true challenge to diversity comes later.
“A critical bottleneck in this type of education is the clinical placement,” said Audrey Lyndon, assistant dean of clinical research at NYU Rory Meyers College of Nursing.
Related: ‘The hospital never supported the midwives’: As more birth centers open, their viability hinges on nearby hospitals
Midwifery students have to do up to 1,000 hours of clinical work, including attending births and doing exams of mothers and newborns, before they can complete their degree. In order to do so, they have to find a preceptor, or a practicing midwife willing to take on the additional training work for a nominal fee. Students are typically responsible for covering all expenses, including travel and lodging.
But only 12% of births in the U.S. are attended by midwives, meaning that clinical placements are very hard to find — even for students of universities that are attached to a hospital. For that reason, “we can’t just open the floodgates and accept [more students] even if someone gave us all the money in the world,” said Lyndon.
This is a challenge for all students, but all the more so for those from marginalized backgrounds who want to serve communities where they grew up. “If your community hospitals, even your private facilities, don’t have midwifery services, where are you going to send the students? That is a chronic issue,” said Mimi Niles, a midwife and assistant professor at NYU Rory Meyers College of Nursing.
Racism and financial pressures faced by midwives in training
Michelle Drew, a midwife and the director of Ubuntu, a collective of health care and community workers serving Black families in Delaware, is a Black midwife who routinely precepts trainees. She’s familiar with the challenges students routinely face in finding placements. One student Drew recently worked with was an African American woman from Dallas, Texas, who was married with children, and had to leave her family behind and move all the way to Wilmington, Del., to find a preceptor and get the clinical experience required to graduate.
This is not uncommon: Students often have to travel long distances in order to find a placement. They may end up waiting to be placed for so long that they have to pay for extra semesters so that they remain eligible for placements and lose potential earnings as they wait to start their practice.
Black students and other students of color may face challenges that go beyond placement availability. As a trainee, Drew experienced firsthand the additional difficulties posed by racism. “When I was a student, I was sent to a location in Kentucky where one of the local churches was an actual meeting place for the Ku Klux Klan,” she said.
Racist obstacles faced by Black midwives in training may not always present themselves in similarly overt ways, but they are very much a reality, Drew said.
“I’ve had many students who’ve contacted me where they interviewed somewhere and were accepted and then they showed up and the particular preceptor didn’t realize that [the students were] African American or Native,” she said. “And then they met the student in person and thought that that particular student wouldn’t be a, quote, good fit for their clients, most of whom are white.”
With this in mind, Drew said, educational institutions should ensure not only that all of their midwifery students find placement, but that these placements are in environments that are supportive and safe. This may mean considering reducing the size of their programs, even if expanding as more students are attracted to careers in midwifery can be financially appealing.
The number of midwifery students continues to increase, but “the demand isn’t growing as fast as the potential workforce is,” said Drew.
“If we really believe we want to serve the community, then we have to make sure that we’re not taking [too many] students and driving students of underrepresented communities into debt when we’re in a country that does not provide education for free,” she said. The cost of obtaining a degree in midwifery ranges depending on the school, but it can reach more than $30,000 per year.
Changing the funding model for midwife education
It’s a vicious circle: Without more clinical placements, it will take a long time to significantly expand the midwife workforce. Without more midwives, fewer people will be exposed to their work, and demand in the U.S. will remain low. With low demand, there will be no incentive for hospitals to expand their midwifery services, so the number of potential preceptors won’t go up. And all that means that pursuing careers as midwives potentially puts a large financial burden on students from underrepresented groups who are so desperately needed to work in the communities experiencing the worst toll of maternal mortality and morbidity.
“These are multi-level issues that are going to require, unfortunately, more time than we think to really create solutions,” said Lyndon. But she remains hopeful that progress is moving in the right direction, in particular with deliberate focus on diversity in recruiting students through initiatives such as the NYU-Howard partnership.
“As we are able to develop more midwives of color, it becomes self-sustaining over time, as we increase the number of people who can give the right kind of preceptorship, the right kind of clinical training, and who can be in practice together in a particular place,” she said.
Key to this future is expanding the number of hospitals hosting midwife training. One policy reform that could help: changing how midwife education is funded.
“Medical education is financed by the U.S. government. They pay [medical] preceptors, residents get paid salaries in order to go to school and work, […] and they get salaries that they can pretty much live on. [Midwives] don’t get any of that,” said Susan Altman, the former director of the nurse-midwifery program at NYU Rory Meyers College of Nursing.
A recent report released by the Office of Government Accountability showed that the financial support provided by the Department of Health and Human Services to midwife education was abysmal: In 2022, out of about 4,000 midwife students, only 22 received scholarships, and less than 400 were awarded loan repayment support. This is the largest pool of recipients so far.
Hospitals also get reimbursed by Medicare for the costs of training physicians, which isn’t typically the case for midwives. That means they have an incentive to open training opportunities for doctors rather than midwives. “Where we put our money demonstrates what we value, right?” said Niles. “So is this country going to step up and say we authentically want to address this?”
Ultimately, Altman said, her hope is that expanding midwifery programs while supporting students will help shift the balance of power in the American health care system to better support new moms. “I’ve been doing this for 27 years, and I still have my elevator speech,” she said. “We have master’s degrees, we don’t — you know — watch a few births, catch a few babies with our Birkenstocks on; that’s not who we all are.”