Making Room for Midwives

Midwives aren’t often featured in The Green Journal, the official publication of the American College of Obstetrics and Gynecology, but the authors of an article published in the current issue are hoping to change that.

Chitra Akileswaran, MD, MBS and Margaret Hutchison, CNM, MSN co-wrote “Making Room at the Table for Obstetrics, Midwifery, and a Culture of Normalcy Within Maternity Care.” They hope that seating more midwives at the tables where maternal healthcare decisions are made will improve childbirth practices for all women.

The article proposes that the medical model that we use for maternal health care in the U.S. is based on the principle that childbirth is dangerous for some women. It leads with the premise that using a variety of medical interventions on all women will help us avoid the worst possible outcomes and reduce morbidity and mortality in childbirth. That principal worked well during the 20th Century, but medical technologies have evolved and medical systems have become more complicated. We now routinely use layers of medical interventions and technologies on even low-risk pregnancies and we’re seeing increasingly poor results.

Akileswran and Hutchison argue that our current state of maternal healthcare is crying out for change. They suggest that embracing a “culture of normalcy” that places midwifery on equal footing with obstetrics will deliver major improvements in maternal health outcomes for all women.

They write, “Given the many evidence-based practices demonstrating the strengths of midwifery to actualize patient-centered, low-intervention birth, we advocate for the explicit establishment of professional standards for team-based physician–midwife care. More than merely introducing midwives into a physician-dominated setting, this means elevating the contributions of midwives and meaningfully incorporating a culture of normalcy to standardize practices.”

Hutchinson works at Zuckerberg San Francisco General Hospital as a midwife and is a member of the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences. We had a few questions about how a culture of normalcy would make a difference.

Every Mother Counts: Why did you decide to publish this piece in the Green Journal?

Hutchinson: Getting a piece like this published in a midwifery journal wouldn’t do a whole lot. It’s preaching to the choir. We’re at a point nationally where really hard questions are being asked about the culture and quality of maternal healthcare. We’re looking for ways that our whole system can become more integrated. We all have to come out of our silos a little and come together to care for our patients. Part of taking on the culture of maternity care is finding ways for midwives and obstetricians to initiate and engage in real conversations. We need to be talking about what midwifery brings to maternity care, particularly in hospitals where most midwives practice.

Every Mother Counts: How does the power dynamic that currently exists between obstetrics and midwifery impact these conversations?

Hutchison: Many midwives train and practice within a hierarchical medical system where doctors are on top and midwives “help out.” This can make it difficult for midwives to fully practice the midwifery model, and to operate at the full potential of their skill set. Within the hierarchy of these medical systems it’s also challenging for midwives to advocate for something different; often, the fact that midwives think differently about childbearing than most physicians isn’t recognized or understood.

Every Mother Counts: What is the “culture of normalcy” you propose?

Hutchison: It’s a lens or a way of seeing childbearing that holds it as an essentially normal process. It’s a life transition, not an illness. And in a labor and delivery unit it assumes normalcy in the processes of childbearing and creates systems to support those processes.

Every Mother Counts: That’s a big contrast from the intervention-based culture of care that’s commonplace in most maternity units.

Hutchison: Right. Currently, we look at everybody regardless of risk status as having the potential for complications, even women who don’t have any medical co-morbidities or complications might impact the labor process. Even women who have medical conditions, like diabetes, can go through normal labor. She may have some issues that need to be addressed but she still has the potential to undergo normal childbearing processes, with a body that knows how to give birth. How do we shift the lens so that the majority of women are first seen as women undergoing normal processes that should be supported, rather than as women beginning an essentially risky process?

Every Mother Counts: Can you give me an example of what that looks like during labor?

Hutchison: A perfect example is the commonplace practice of using continuous fetal monitoring throughout labor on almost all patients. The data doesn’t support it as being beneficial for low-risk women. It leads to a cascade of other interventions, increases risks for C-section and hasn’t improved babies’ outcomes. Yet it remains a major part of most hospital-based labors. Fetal heart monitoring started out as a screening tool, to check in on babies from time to time and make sure they’re managing pregnancy and labor well. It turned into a diagnostic tool, and has led to increased c-sections and a decrease in things that we know support normal labor processes like women’s mobility and the focused attention of care providers. You have to ask why we’re still doing this when we know it’s not helping mothers or babies.

Every Mother Counts: You wrote that the most powerful determinate of a patient’s experience is the provider who takes care of her. Can you explain that?

Hutchison: A healthcare provider’s belief system and practice style has a huge impact on her patient, whether she’s a midwife or obstetrician. When your provider practices a model of care that’s high-intervention and risk-based instead of a model that starts with the assumption that your body is normal, you’re at higher risk for getting more medical intervention than you need or than is necessarily good for you. I’m hoping that this article will help people initiate and engage in conversations about where midwifery fits in a changing maternal healthcare landscape.


Every Mother Counts with Jennie Joseph, founder of Commonsense Childbirth, co-created a petition on Change.org to call on insurance companies and state Medicaid programs to fully reimburse for midwifery and doula care in all 50 states. Help us reach our goal of 100,000 supporters. Sign your name here to help us make motherhood safer in the U.S.

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