Midwifery Practices Across the U.S.

More patients are considering a wide variety of birth options, and health systems and independent birth centers are expanding their midwifery practices to meet the demand. That is only one of the findings from a recent survey ECG conducted of midwife practices across a variety of settings.

ECG’s Women’s Health team closely monitors trends in women’s healthcare delivery, and several changes in the obstetric provider landscape prompted us to conduct this survey. Specifically:

• Birth rates are stabilizing.
• Labor and delivery closures are common.
• An increasing number of patients are reportedly seeking their birth experience outside of the traditional hospital setting.

The 31 respondents represented a mix of hospitals and health systems (52%), independent birth center settings (32%), and other practice settings (16%).

The purpose of the survey was to help us assess the current state of midwifery and discern differences among midwife practices. Questions focused on organizational demographics, strategy, operations, and compensation.

Respondents were asked to consider the future of their midwifery practices and rank four strategic options: increase the number of midwives, expand their geographic reach, expand inpatient coverage, and expand outpatient services. Across the board, the most popular growth strategy was to increase the number of midwives, followed generally by growing outpatient and inpatient services.

Group Demographics

On average, hospital and health system employed midwife groups tend to be larger than the birth center groups, with nearly 12 midwives and 3 midwives, respectively. Hospital and health system midwife groups also tend to cover more inpatient and outpatient locations; they have more than one additional midwife FTE in each delivery location than do birth center groups. The average midwife group in hospitals and health systems covers 3 to 4 delivery locations and 5 outpatient locations. Birth center group midwives cover 1 to 2 delivery locations and 1 to 2 outpatient locations.

Together, the respondents from our survey attend nearly 7,000 births per year. The largest health system midwife group has more than 1,900 deliveries per year, and the largest independent practice group has 400 deliveries per year. On a per FTE basis, midwives in hospital/health system groups attend nearly twice as many births as the birth center midwives.

Practice Operations

Midwives surveyed are generally heavily engaged in the full scope of midwifery services, in multiple settings, attending births and providing services while on call. As one might expect, all midwives in hospital and health system settings attend births in the hospital, compared to about one-quarter of midwives from independent birth centers. More than 1 in 3 birth center midwives attend births in patients’ homes, while only 1 in 8 hospital and health system midwives do.

Home Births

For many years, home births were relatively consistent across the country at over 38,000 per year; in 2020, that number increased to over 45,000, likely as a result of the COVID-19 pandemic. The share of births that took place at home was 1.3% in 2020 compared to 1.0% in 2019.

Call Coverage

Regardless of the setting, being on call is a typical part of the midwife role, with between 6 and 10 call shifts per month at both independent birth centers and hospitals/health systems. The vast majority of call shifts are unrestricted and 24 hours in duration. When coverage changes and midwives are asked to take excess call above their required shifts, most (70%) are not paid for that additional coverage.

Midwifery in Outpatient Settings

All of the hospital/health system midwives have outpatient practices, while only about three-quarters of independent birth center midwives do. Appointment times between hospital/health system groups and birth center groups in those office/ambulatory settings vary significantly and consistently, with the independent birth center midwives reporting that all appointment types are at least 25% longer than their hospital and health system counterparts. For example, postpartum visits are more than twice as long in independent birth centers (45 minutes) than they are in the hospital setting (20 minutes). It’s important to note that the longer appointment time is not necessarily an indication of inefficiency; ACOG and other organizations emphasize the importance of postpartum care and describe it as a “ongoing process, rather than a single encounter” in their position statement on Optimizing Postpartum Care.

Midwife/Physician Collaboration

Eighty-six percent of responding organizations report that midwives have collaborative relationships with OB/GYN physicians, while 41% reported their midwives are independent with no collaborative partnership with physicians. Six of 22 (27%) organizations said their midwives practice both collaboratively with, and independently of, physicians. In most cases, organizations offered that these midwives are practicing independently and then collaborating on high-risk patients, MFM referrals, etc.

Summary

While this initial data set shows some variability between midwife practice types and makeups, there are also areas of consistency that align with organizational goals for providing high-quality care. In particular:

• Patient engagement and satisfaction tend to be excellent for midwife patients, indicating a practice model that provides the compassionate service it intends to deliver.
• Complication rates, c-section rates, and medical cost data are also reportedly low, indicating that not only are patients satisfied with their experience, but that they are getting high-quality care.^[1]

If your organization partners with midwives or is considering doing so, carefully examine your practice to ensure there is a good balance of operations, job structure and compensation, and strategy so these practices can provide the excellent care they are known for.